New in Science: "Evidence, Alarm and the Debate Over E-Cigarettes"

A new review essay in Science warns of the dangers of prohibitionist thinking

A new article in Science, "Evidence, alarm, and the debate over e-cigarettes," warns that, when it comes to vaping, "prohibitionist measures threaten public health." This may not be news to those that have followed the burgeoning medical and social science literature on e-cigarettes and vaping, but it is quite notable to see this message in a journal as prestigious as Science.

Written by researchers from the schools of public health at Ohio State, Emory, New York University and Columbia, the article explains the importance adopting prudent harm reduction strategies to address the health consequences of tobacco use and the risks of adopting unnecessarily prohibitionist or restrictive policies.

The article begins:

This is a moment for legitimate alarm at the intersection of two distressing but distinct epidemiological patterns involving e-cigarettes ("vaping"): an increase in vaping among youth and a sudden outbreak of acute lung injuries and deaths in the United States, associated most strongly with vaping tetrahydrocannabinol (THC), the main psychoactive compound in cannabis. Discussions of vaping, however, often neglect distinctions between nicotine and THC; between adults and youth; and between products obtained through the retail and black markets. As we move to confront these challenges, we face the danger that justifiable alarm will turn alarmist, short-circuiting careful analysis of the full range of evidence and focusing attention on the most frightening, thus enhancing the prospect of adopting counterproductive policy. We suggest that the evidence warns against prohibitionist measures. Restricting access and appeal among less harmful vaping products out of an abundance of caution while leaving deadly combustible products on the market does not protect public health. It threatens to derail a trend that could hasten the demise of cigarettes, poised to take a billion lives this century.

Surveying the relevant literature, the article notes that there is widespread support for the proposition that "vaping nicotine is much safer than smoking" and that "Careful analysis of all the data in context indicates that the net benefits of vaped nicotine products outweigh the feared harms to youth." Among other things, the authors note, is that e-cigarettes have been shown to be "more effective than medicinal NRTs [nicotine replacement therapies] at helping smokers quite" and that the availability of flavors often play a key role in helping smokers quit.

They write:

The most conservative estimates suggest that were vaping nicotine to replace most smoking over the next 10 years, 1.6 million premature deaths would be avoided and 20.8 million quality adjusted years of life would be saved in the United States alone. The greatest gains would be among younger cohorts.

Despite the growing body of research supporting the role of e-cigarettes as part of a broader tobacco harm reduction strategy, regulatory measures threatening to squelch the e-cigarette market and curtail the usefulness of vaping as a smoking cessation tool proliferate at all levels of government. Perhaps this article will help turn the tide and lead to more effective -- and more life-saving -- approach to tobacco.

Comments

[Stephen Lathrop]

Science is prestigious? Nah. Nature is prestigious.

[Á àß äẞç ãþÇđ âÞ¢Đæ ǎB€Ðëf ảhf]

Used to be. They've gone pretty retard the last few years, with editorials preaching gun control, a very sciencey subject for sure. Then there's the Hall of shame they thought appropriate.

[Stephen Lathrop]

From the article: Proposed solutions that conflate vaping THC oils with nicotine or with flavors, and that may lose sight of population-wide issues while focusing on subsets of the population (4, 6, 8, 9), may do more harm than good.

Or, they may do more good than harm. Problem is, none of the data relied upon in the article take useful account of the sudden upsurge in acute illness related to vaping. The studies cited have been obsoleted by the epidemic.

Investigators are trying to sort that out, but the problem is complicated by the fact (unmentioned in the linked article) that there is a large—but as yet not accurately quantified—overlap in vaping types (THC and nicotine) among the acute victims. That tends to make assertions that black-market THC products are causing the acute illnesses less than convincing.

What if the recent acute illnesses are instead a result of cumulative exposure to either product, or both products interacting, or to some as yet undiscovered factor related to vaping itself? Confident policy recommendations amidst this much uncertainty do not inspire confidence.

Investigators are trying to sort those questions out. Marketers and propagandists are trying to make the most out of bits of data which are meaningless until more context and study do the sorting.

[Robert Beckman]

You have that backwards, actually.

There’s a large population of nicotine vapers who only use commercially available products (not counting a THC hand load you might find at a head shop), and they universally have complications in line with the non-user base rate. This group forms the natural second control for the two part tests needed for a combined drug reaction.

So we have:
Non-users
Nicotine only
THC and Nicotine
THC only (and substances the user believed to be THC)

And the complication rates of non-users and nicotine only users are almost identical, and the complication rate for each of the two THC use groups is approximately linear, which not only rules out nicotine vaping as an acute cause but also shows that it’s either a linear dose response or a risk per use.

For context, risk per use is what occurs with infections and IV drug use - what matters isn’t the amount of drug consumed, but how many times it’s injected. None of the data collected and either published or not-yet-published from any of the major research groups has teased out yet whether it’s actually a dose response yet, probably because vowing is inherently a very high use count consumable, which approximates a linear dose consumption (for example, when multiple people vape they all take approximately the same amount of drug, so you can calculate the drug dose based on number of “puffs” and vice versa. If the risk is linear per use it will look just the same as linear drug dosage).

What we don’t have yet is the prevalence of switching from vaping to regular use of less-safe delivery methods - chew or cigars being the most prominent - without regulatory barriers, and the same transition rate with regulatory barriers. We have no reason to think this will be a significant rate, but we don’t know.

We also don’t know the long term effects of highs done nicotine use which becomes easier with vaping. Our best guess is that it will approximate high caffeine use but with lower risks of acute fatalities (go drink 10 energy drinks quickly back to back and you won’t make it to the 10th - and that’s not a suicide suggestion). We’ve seen multiple instances of high nicotine doses from children putting dozens of patches on at once without fatalities, so we don’t think that will happen.

[Stephen Lathrop]

There’s a large population of nicotine vapers who only use commercially available products (not counting a THC hand load you might find at a head shop), and they universally have complications in line with the non-user base rate.

Can you say a bit more about what that means? My thought would be that, "complications," must by definition be linked to the practice to which they are attributed. Meaning that non-user, "complications," would always be zero. If you are asserting there are no user complications for nicotine-only vaping, all I can say is stick around, it's early days.

[gormadoc]

Complications would include things like cancers or other disorders around the mouth and lungs for tobacco users. Lung cancer is predominantly caused by smoking but non-users still get it from time-to-time. Oral cancer is predominantly caused by chew but non-users can also get it.

Nicotine itself is not believed to be carcinogenic; it's the stuff that comes along with it in the consumption method. It turns out that it's not a good idea to breathe in smoke for significant portions of your day, especially when that smoke contains carcinogens. Nicotine may have effects on fetal development and children's brain development, though that is still an open topic. Otherwise nicotine is considered to be similar to caffeine in its "badness" as a drug. Addictive, but not otherwise harmful.

[Robert Beckman]

Gormadoc has it right, and I’ll add more.

Complications includes things like all-cause mortality, cardiac arrests, strokes, etc.

There’s a common set of reference disorders we look at when we don’t have any specific theories about causation (so in this case we expect to see a difference in respiratory illnesses and lung cancer). Each of these has a base rate in the population at large, which can be further subdivided into common populations and co-morbidities (ex: obese people have more strokes than those with normal BMI - as do those with very low BMIs).

When we compare self-identified nicotine-only users we don’t see any statistically significant differences in either all-cause mortality (which tells you there’s something there, even if not what) and in any of the specified causes (which would indicate future changes in all-cause mortality, for example if we started seeing more strokes in young people that may not show up in mortality rates yet).

To your point though - that doesn’t mean something won’t develop, but if it does it will necessary be either very subtle (something that could be found today, but hasn’t yet) or due to long term use (which we can’t tell yet since this hasn’t been ongoing long enough). Long term use only things are like the various reports on red wine consumption - small amounts over decades seems to help, but it’s a benefit over decades only and won’t help anything quickly (also chocolate, coffee, and a handful of others, but all with small enough increments that they could just be noise).

[Rossami]

What if the moon were made of green cheese? It might all melt during the next big solar flare and then crash into the earth. That's about as fact-based as your suppositions on the dangers of vaping. It's not really complicated - the "recent acute illnesses" associated with vaping have been conclusively traced to contamination of black-market products.

This entire debate over vaping is a classic example of the Precautionary Principle Fallacy. New things are suppressed or withheld because they cannot be proven safe while ignoring the known dangers of the older alternatives. The Precautionary Principle is a broken, unbalanced model that produces no useful guidance for real-world decision-making.

[Á àß äẞç ãþÇđ âÞ¢Đæ ǎB€Ðëf ảhf]

Never do anything the first time.

Never let anybody else do anything the first time.

[Tempe Jeff]

I refuse to tell my 11 year-old son that he should never make love to a woman he marries. Your moralistic statement is balderdash.

[Robert Beckman]

This is why a risk matrix is the right approach, so that you can compare partially known options - since nothing is ever fully understood.

The problem with this hysteria (and the precautionary principle more broadly) is that it’s not comparing like classes. We shouldn’t be comparing the risks of vaping in ways far outside any makers expectations with the risks of cigarettes in their usual form. If we want the “how bad could it be” version we have to compare vaping THC (which still isn’t that dangerous) with smoking a cigarette whose tobacco has been replaced with methamphetamine or fentanyl (the other hysteria du jour whose only major risk is because of adulteration caused by market restrictions).

But the precautionary principle is never actually followed, it’s only ever used to prevent new competition with a bootleggers and Baptists coalition. Anyone who actually followed the precautionary principle would die of thirst (this water may have lead in it!), followed by a toxic colon (better not defecate or I might get an anal fissure) followed by starvation (e.coli!). And an argument that this is a reductio ad absurdum doesn’t work, because the precautionary principle itself is a reductio ad absurdum - that’s the point.

[Stephen Lathrop]

Rossami, here is some useful, real-world advice from the precautionary principle: Do not let researchers use CRISPR to modify the heritable genome of staple crops, and then release those modified plants into the wild.

That will remain sound guidance until genetic modification experts achieve the capacity to design from scratch duplicates of existing organisms, including organisms as genetically complex as insects, reptiles, birds, and mammals. Until that happens, genetic engineers haven't got any eraser on their pencil. Until there is an eraser, the world cannot afford to live with purposeful, reckless, happenstance which deliberately targets the most relied-upon natural organisms.

[Absaroka]

Can you flesh that out a little? You seem to be positing some kind of 'Attack of the Killer Soybeans', where modified soybean plants are like weeds, crowding out the varieties that farmers plant. There are cogent concerns about genetic tinkering, but that doesn't seem like one of them.

[Dilan Esper]

Here's the thing. There's two separate concerns here.

If vaping is actually seriously unsafe and is going to kill or seriously injure large numbers of people, then yes, we should try to make it safer and if it can't be made safer, severely restrict it (basically the way we restrict other smoking-cessation products).

On the other hand, if the worry is simply one of addiction, but vaping is relatively safe, that's a moral panic. And we need to stop having moral panics about teenagers experimenting with psychoactive substances. Right now, hundreds if not thousands of teenagers are either killed or are starting a causal chain that will lead to their deaths by experimenting with alcohol. I assure you that whatever the number is for vaping, it is far lower than that. Nonetheless, there is no moral panic about teenage drinking. (We could have, for instance, had a conversation about it after the Brett Kavanaugh hearings. Because no matter how one felt about the specifics of what happened, it is clear that Kavanaugh and his friends drank far, far, far too much in high school and college. We didn't have that conversation.)

We really need to stop having moral panics. How many black people had to go to prison because suburban whites were up in arms about the supposed dangers of teenagers smoking marijuana?

These sorts of panics aren't costless.

[Robert Beckman]

Sadly I think that partisanship is (largely) why we didn’t have that conversation.

Ford’s claim was at least plausible, even if many thought it was so unlikely, had so many inconsistencies, and was so clearly politically motivated that it should be discarded outright. But when the other claims started to come in that weren’t even plausible that just made the entire ordeal look like a hit job - and even made many who were borderline on thinking that’s Fords claim raised enough doubt on Kavanaugh that (even if likely untrue) cast enough doubt that he shouldn’t be confirmed ultimately came to believe that it all was an orchestrated political assassination that shouldn’t be countenanced.

If instead the Democrats had used to allegations not as a reason to reject the candidate but to raise alcoholism as a major issue we could have had that national discussion. Positioning it’s something like “here’s an allegation of prior wrongdoing because of alcohol - while we can never know if it happened that way because of the alcohol it shows that we have a societal issue we need to address.” The Republicans likely would have jumped on it to get their guy through with little objection, and the Democrats could have used it to push through some of their policy preferences claiming it was something the Republicans highlighted for them. While the Republicans could have tried a similar tactic there was less reason for the Democrats to adopt it, as successfully rejecting an opponents Supreme Court nomination has great political effects.

[dwb68]

It wont turn the tide: there are several entrenched institutions, including states themselves, dependent on taxes from tobacco sales. Taxes are supposed to reduce demand, in reality governments spent the money and now have an incentive to keep tax revenues flowing. I am 100% sure there is no conflict of interest when high tax states like NY complain about the harm of vaping.

[Krayt]

Juul is owned by a tobbacco company and is falling on its sword to drag down the vaping industry by "getting ahead of the curve" and "leading responsibly" by removing products from 97,000 shelves and putting up huge scary warning signs. "Shouldn't we be regulated? All vaping companies should!"

It's no coincidence this other scare came out at the same time and is being hammered on.

[Krayt]

It's the Phantom Menace. Emperor Tobacco should use his emergency powers to crush vaping thanks to FUD.

[Kazinski]

Actually Juul is 20% owned by a tobacco company, which is a far cry from control.

Juul maybe trying to bend over backwards for the regulators but that is too head off more regulations, not to kill the product at the behest of the tobacco companies. It would be hard to argue with the moral panic going on about vaping that there is not a risk of the regulators killing the industry.

[Robert Beckman]

20% is often easily enough to control a company, so long as the rest is highly diluted. I’d guess it’s the other way around with Juul with the founders holding a majority shareholder position, but with highly distributed corporations you can often control it with under 10% of voting shares.

Think of it this was - if a choice is reasonable then it’ll get about 50% by itself (where an actively good idea will get more, and an actively bad idea will get less). With your 10% you can tip every reasonable vote your way, giving you effective control over everything that isn’t stupid.

[anorlunda]

That's a pretty remarkable and rare appeal. Be alarmed but not alarmist. I can't remember a recent example of a similar appeal.

But it's futile. That's not the way the modern world works. It will either be ignored, or the reaction will be alarmist. Measured rational reactions to anything are not in the modern repertoire.

If the scientists want to get their way, they need to be hysterical.

[NoVaNick]

The current vaping hysteria is promoted not only by states that have a financial interest in tobacco tax revenue, but by academics and health non profits that have built entire careers out of demonizing smoking, which vaping undermines. I have been vaping for 10 years now and have avoided cigarettes for 6 of those, while I am not sure that vaping is 100% risk-free, I can now run for 5 miles that I couldn’t do before, I don’t get respiratory infections nearly as often, and I no longer have an irregular heartbeat. Am I a nicotine addict? Yes! But if I am not suffering any health problems, what difference does it make? It’s a moral issue-then again, the government has never shied away from banning things simply because it finds them morally objectionable (see porn, pot, and sodomy).

[Stephen Lathrop]

No room for moral objections to addiction-based business models?

There are at least two objections to addiction-based business which strike me as supportable. First, they take a heavy toll on the poor. Vaping may be a financial nothing-burger for you, but for someone stuck with a minimum wage burger-flipping job, it will be financially burdensome or worse. People tend to acquire smoking and vaping addictions gradually, and in their youth, when the cost issues seem less imposing. Later on, the relentless financial drag takes a continuing toll, not only on the user, but on dependents. I get that libertarians don't care.

Second, addicted people never affect only themselves. Others, including others not dependents, are inevitably affected, and typically get no choice in the matter. However safe you think your vaping products are, I don't want to be a second-hand consumer of them, not even slightly. Because everyone was sure cigarette smoking was benign, I grew up in a household with a cumulative 4-pack-a-day tobacco habit. Why re-start that? It's not a morally strong position to say, I predict it's safe, so it's my right to inflict it on everyone else.

[Brett Bellmore]

How unfree do we have to make society to protect people with addictive personalities from themselves, though?

It's not as though prohibition doesn't effect people besides the drug users, too. Even setting aside basic libertarian concerns about individual liberty to do things other people think unwise.

Prohibition drives government corruption, funds a criminal underclass, creating crimes that effect people other than the drug users.

That's my real objection to prohibition, frankly: I really am not that sympathetic towards drug users, but prohibition harms people sensible enough to NOT use drugs.

[Dilan Esper]

"No room for moral objections to addiction-based business models?"

Many business models, from White Castle to casinos to shopping for apparel, are addiction-based.

Unless you want to abolish capitalism, there's nothing wrong with trying to hook people on your product, as long as it is reasonably safe.

[Tempe Jeff]

What? You're not dying of Cancer of the lung, right this very second? Sue your parents you ignorant clod. You have no right to, demand I change for your moralistic preening. You are insufferable. I don't drive by choice but, I would never demand motor vehicles be banned for my idiosyncrasies. Matter of fact, I only ask my fellow humans to try to play nice with each other. Giving the benefit of the doubt and, simple manners demand it.

[Robert Beckman]

Yours is mostly a matter of disagreement on the role of government.

Should the government protect the liberty of the populace, or ensure the wellness (as the government sees it) of the populace? Everyone draws the line differently, and yours is just further to the intervention side that most libertarians.

But to your comment that libertarians don’t care, that’s just wrong. We care a lot about the wellbeing of our fellow man, we just value their liberty above almost everything else.

When the question is, “what is best in life?” We don’t think the only acceptable answer is “ To crush your enemies, to see them driven before you, and to hear the lamentations of their women.” Instead we say that each individual must decide for themselves what is best in life. So when a person concludes that eating healthy foods and exercising regularly is what’s right for them we say “great!” And when they say they just want to each cheeseburgers, watch TV and never bathe we say “gross, but go for it as long as you stay downwind from me.” And that’s the key part - living your life the way you think is optimal, so long as you don’t cause any externalities.

So libertarians really do care, maybe even more than most others, but we care consistently about people making their own choices about what’s good in life.

[Armchair Lawyer]

Really, the largest issue is this.

Vaping is "supposed" to be a replacement for current smokers. And in so much as that's true, it may be better from a risk management type of situation. You go from high/medium risk to medium/low risk

But if vaping is attracting new people who have never smoked before, then that's an entirely different risk management. Now you've gone from zero risk to low/medium risk. And really that's what's going on. Vaping is attracting new people (especially teens) in high numbers who didn't smoke before.

[Brett Bellmore]

Part of the question here, is, "How risky does something have to get before regulation is in order?"

I mean, eating instant ramen isn't exactly good for you. Drinking 2-4 liters of Mountain Dew isn't great, either.

At some point I think you've got to say, "You know what? Yes, this is risky, but we let people do comparably risky things all the time. So, whatever, it's your life."

[Armchair Lawyer]

There is a point where you've got to say "yes, this is risky..." IE, Mountain Dew. But there's also a point at which you say "Oh hell no, we're going to put barriers in the way to stop you from killing yourself" IE Fentanyl. And then there's a whole lot of stuff in between.

And when you're evaluating that stuff in between Mountain Dew and Fentanyl, you've got to take a whole lot into consideration. Marketing, usage, youth usage/risk, safety, risk mitigation, long term effects, etc.

So, when you look at something like vaping, not only do you need to look at the effects in risk mitigation (which is what's being promoted in terms of smoking alleviation), you also need to look at the other effects, especially in youth usage/risk. And when these stupid kids think that all that's in these vaping cartridges is flavoring, with nearly 40% of high school seniors vaping....maybe some increased education/restrictions are in order. This isn't chewing gum. You don't see a rush of teenagers slapping nicotine patches on their arm. But you do see the mass increase in vaping.

[donojack]

Regulation of minors' use of substances should be separated from that of adult use. We can and should have strong prohibitions against selling these products to minors. If the laws prove to be ineffective in curtailing sales to minors it points more to the laws needing more teeth than to the need for stiffer regulation or prohibition of the products themselves. For adults I'm in the camp of letting them choose to use or abuse substances at will.

[Armchair Lawyer]

Unfortunately, the two are not entirely disconnected. And regulation is only part of the issue. Marketing and education play major roles as well.

Smoking rates in the US have dropped dramatically, from over 40% of the population smoking in 1970 to 14% in 2017. By and large this was mostly not due to regulation, but due to massive marketing, education, and cultural changes. Vaping is threatening to reverse that in the upcoming generation. And while it might be slightly better than smoking, it's still not really safe.

The two (smoking and vaping) really need to be treated the same, in terms of regulation, education and cultural impact.

[Brett Bellmore]

"And while it might be slightly better than smoking, it’s still not really safe."

Nah, I think the science actually says that it's a LOT safer than smoking, and in the same ballpark as other routine bad habits we don't think twice about letting people indulge in, so long as you're not talking black market vaping compounds.

[Dilan Esper]

Oh hell no, we’re going to put barriers in the way to stop you from killing yourself"

i would buy this if we had much stricter regulation of alcohol. But we don't. We recognize that people have the freedom to ingest even very seriously dangerous substances that can kill themselves and others.

[Stephen Lathrop]

Dilan, perhaps we can discern a policy difference between an addictive industry business model already firmly established, and one that is just now trying to get a toehold by marketing to teens. In the former case, because of addictions customers already have, prohibition become impractical. In the latter case, addictions might be preventable by prohibition, making that policy more workable.

[Dilan Esper]

I don't discern any policy difference. "We got there first and have poisoned millions more people" does not strike me as persuasive at all.

And guess what, the alcohol industry markets to teens ALL THE TIME. Everything from the beach party aesthetic in the adds to the flavored hard lemonades and coolers.

You can't just say "Prohibition is impractical". WHY was it impractical. It was impractical because it seriously impinged on what is actually a basic human freedom, which is to take risks and intoxicate yourself without other people getting to force you to stop because they know what's good for you. That's why it failed. Because eventually the American public recognized that harming yourself, if you wish to, is actually a crucial part of human autonomy.

And as I said upthread, our failure to respect this freedom with respect to marijuana resulted in the incarceration of tens of thousands of young black males who did nothing wrong except sell or possess a fun product.

I am fine with all sorts of truthful warning labels on vaping products. And definitely, if there is a safety risk due to chemicals in the formula, that's a valid subject of federal regulation. But my basic view on these substances is I don't think Stephen Lathrop, or any other person, has either a morally superior or intellectually superior position to decide what is bad for another person to do. We need to get OUT of the moral panic business, before the policies you favor throw another generation of young black males in prison.

[gormadoc]

The question isn't really if it's attracting people who've never smoked, it's if it's attracting people who've never smoked and never would have. Most of the teens who fall under the first don't fall under the second and therefore aren't a negative consequence of vaping but of whatever drives people to smoke or vape.

[Armchair Lawyer]

"Most of the teens who fall under the first don’t fall under the second"

That's entirely speculation, with no evidence to back it up.

[Rossami]

Gormadoc beat me to it with the correction to your metric. For any behavior X, there will always be new teens taking it up simply because they are new teens. The correct measure is teens taking it up who would not have done Y instead.

And while you are correct that gormadoc provides no evidence for your claim about frequency, neither did you in your original post.

From the evidence that I've seen, the number of teens smoking is down sharply, the number of teens vaping is up by about the same amount and the total amount of nicotine consumed through both channels is down slightly. (Apologies but I don't remember where I read that study. I'll come back and add a link if/when I can find it again.) I am aware of no evidence whatsoever supporting your claim that "vaping is threatening to reverse" the reduction in smoking rates in the US.

[Stephen Lathrop]

Those points are belied by the notable decline in cigarette smoking among teens, prior to the vaping boom.

[gormadoc]

It's been pretty much a linear decrease since the late 80s, excepting the smoking boom in the 90s. In fact, if you take treat that linear trend as a baseline the 90s just look like a bump on the top of it. Since we've been hitting lows every year since 2002 or so, it wouldn't be weird for even a momentary reversal of that trend, whether due to demographic change (foreign methods of tobacco consumption are trendy now, like hookahs and certain smokes) or product change (I don't believe vaping contributes now but I wouldn't be surprised if it does in 10 years).

[Armchair Lawyer]

The CDC statistics on teen tobacco use contradict this.

In 2011, 15.8% of high school students smoked cigarettes. This proceeded downwards to 4.3% in 2019. However, the number of high school students vaping went from 0% in 2011 to 27.5%, well eclipsing the number who dropped cigarettes.

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm

[Rossami]

The CDC's methodology in that report has already been extensively criticized. For example, they have traditionally used a definition of cigarette smoking that talks about some level of regular use. One-time experimentation was excluded by the wording of their survey question. For vaping, however, the question captures everyone who ever took even a single puff.

The vaping measure also conflates those who vape nicotine-based product with those who vape non-nicotine products.

[gormadoc]

Give me some evidence for your assertion. If you bothered to look into it at all and see the data and methodologies for yourself you'd see some obvious problems cropping up. It's hard to get the actual numbers when the group in charge of producing those asks the wrong questions.

There are reports that tobacco use has spiked but they stem from CDC questionnaires, which don't actually differentiate between using e-cigs with nicotine and using them without. Flavored non-stimulants are popular, as well as flavored THC. The data analysis also relies on the "once touched forever tainted" principle, where the large number of teens who used an e-cig of any type for less than two weeks (13%) are still counted as tobacco users.

https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/data/index.html

There has been an increase in vaping but it's confounded with the fact that teen tobacco users are using more products than cigarettes now: use of more than one product when they already use one is at 40% now for high-schoolers. It used to be that most urban teens were only smoking to get their fix; there just wasn't much else available. Now they can vape, too, whether to get the nicotine fix or not.

But the underlying point is that wringing our hands about "first time users in their teens" is stupid. Almost everybody who gets addicted to tobacco does so as a young adult under 21, most of those being teens. First time users of most general use nicotine products (smoked, vaped, chewed, snorted, whatever) will therefore be mostly teens.

[Armchair Lawyer]

The point from a social health standpoint is to reduce the number of teens who get addicted to nicotine in the first place. And by and large, the nation was on a consistent downward trend there, with less and less teens using tobacco...until vaping popped up, and made it "cool"

[Grand Moff Tarkin]

Well, according to Time Magazine's person of the year, facts don't matter, evidence does not matter, and science does not matter. One need only look at the hysteria regarding the recent Executive Order regarding Title VI of the Civil Rights Act of 1964 to see how ignorance, stupidity, and partisanship distort how people view issues. People are still arguing that the Executive Order makes deportation of Jews possible.