According to Thomas Ylioja, a "smoking cessation expert" quoted by CBS News, the latest survey data on e-cigarette use by teenagers show "we have a whole generation of young people who are addicted to these products." That premise has been endorsed by Surgeon General Jerome Adams, and it is the rationale for the ban on flavored e-cigarettes that the Food and Drug Administration (FDA) is expected to impose any day now. Yet it is demonstrably false.
In the 2019 National Youth Tobacco Survey (NYTS), according to an article published yesterday in The Journal of the American Medical Association, 27.5 percent of high school students reported using e-cigarettes in the previous month. That translates into 4.1 million teenagers who were "current" e-cigarette users. But how many of them were "addicted to these products"?
Among past-month users, the supplementary tables in the JAMA article show, 34.2 percent reported vaping on 20 or more days in the previous month, while 21.4 percent said they vaped every day. In other words, less than 6 percent of high school students were daily vapers. That represents about 877,000 high school students who might reasonably be described as "addicted to these products," plus another 106,000 or so middle school students who also were vaping every day. If you include all "frequent" e-cigarette users (those who reported vaping on 20 or more days in the previous month), the totals rise to 1.4 million and 216,000, respectively. That's a significant phenomenon, but it hardly qualifies as "a whole generation of young people who are addicted to these products."
Who are these e-cigarette addicts, and what would they be doing if they weren't vaping? A recent analysis of NYTS data, reported in the online journal Qeios, found that frequent use was rare among teenagers who had never smoked. The rate was 0.1 percent in 2017 and 1 percent in 2018. It may be higher this year, since the incidence of frequent use among all high school students rose from 5.8 percent in 2018 to 9.4 percent in 2019. But the general pattern is almost certainly similar: Frequent use (and therefore daily use) is overwhelmingly concentrated among teenagers who have also smoked.
Does that pattern indicate that vaping makes teenagers more likely to smoke? By and large, no. "While it may well be the case that in some individual instances initial trying of an e-cigarette led on to trying and using cigarettes, the data strongly suggest that this is not the dominant pattern observed at the level of the whole population," the authors of the Qeios study wrote. "Among high school students we found that, for the great majority of those with any substantial cigarette smoking history, cigarettes were the first tobacco product tried, prior to any use of e-cigarettes."
An analysis of data from the Monitoring the Future survey published this week in the journal Nicotine & Tobacco Research likewise casts doubt on the fear that vaping leads to smoking. After "accounting for the propensity for using e-cigarettes based on 14 risk factors," the researchers found that "e-cigarette use does not appear to be associated with current, continued smoking." Instead, they said, "the apparent relationship between e-cigarette use and current conventional smoking is fully explained by shared risk factors, thus failing to support claims that e-cigarettes have a causal effect on concurrent conventional smoking among youth."
To the contrary, the NYTS data suggest that vaping is replacing smoking among teenagers. "In 2019," the JAMA article notes, "the prevalence of self-reported current e-cigarette use was high among US high school and middle school students, while self-reported current cigarette smoking among high school students has declined to historic lows."
Might there be a connection between those two opposing trends? The FDA is remarkably incurious about that question, even though it goes to the heart of the public health justification for its ban on flavored e-cigarettes. We do know that frequent e-cigarette use is concentrated among teenagers who also have smoked. We also know that the downward trend in smoking among teenagers and young adults accelerated as e-cigarettes became more popular.
Last August the Substance Abuse and Mental Health Services Administration, in a report on results from its National Survey on Drug Use and Health, acknowledged the likely role of e-cigarettes in reducing smoking rates. "Fewer than 1 in 6 people aged 12 or older in 2018 were past month cigarette smokers," it noted. "Cigarette use generally declined between 2002 and 2018 across all age groups. Some of this decline may reflect the use of electronic vaporizing devices ('vaping'), such as e-cigarettes, as a substitute for delivering nicotine."
The whole point of the FDA's flavor ban is to make e-cigarettes less appealing. But if the result is that teenagers who are vaping start smoking instead, the FDA will be hurting the very population it claims to be helping, since conventional cigarettes are indisputably much more dangerous than their smokeless, tobacco-free competitors. And that's leaving aside the ban's likely impact on the millions of American adults who have switched from smoking to vaping, some of whom are apt to switch back once the products they overwhelmingly prefer are no longer legally available.
The JAMA report notes that the popularity of mint and menthol flavors among teenaged vapers rose between 2018 and 2019, although fruit flavors remained the favorite. Another JAMA article published the same day, based on data from the Monitoring the Future survey, likewise noted that mint is now the most popular flavor among teenagers who use Juul, the leading e-cigarette brand. Both articles imply that it would therefore be reckless for the FDA to exempt mint (and perhaps also menthol) from its flavor ban.
But the reason for the rising popularity of mint pods seems pretty clear: Last fall Juul stopped selling flavors other than mint, menthol, and tobacco to retailers, limiting other varieties to its online store (which as of last month is no longer carrying them either). While other companies continued to sell Juul-compatible pods in the restricted flavors, Juul's decision surely had an impact on the availability of flavors other than mint, menthol, and tobacco. If the FDA bans mint, you can be sure that menthol will become more popular among teenaged vapers. If the ban includes menthol as well as mint, more teenagers will suddenly be using tobacco pods. Will that show that nothing short of an outright ban on e-cigarettes is necessary?
More and more teenagers are vaping, the FDA observes, so the government needs to do something. But what that thing should be depends partly on the harm caused by the rise in adolescent vaping, which in turn depends on the extent of addiction among teenagers who otherwise never would have tried nicotine and the likelihood that they will transition to smoking.
The FDA has not shown much interest in either of those issues, instead conflating past-month e-cigarette use with addiction and simply assuming that e-cigarettes are a gateway to the real thing, notwithstanding the lack of evidence to support that hypothesis. Worse, the FDA has paid hardly any attention to the harm caused by its response to underage vaping, which will lead to more use of potentially tainted black-market products and more smoking-related disease and death. You cannot weigh the costs and benefits of a policy if you ignore its unintended but predictable consequences.