Sales of flavoured vapes could soon be severely restricted in the US, ostensibly to protect young people from potential harm. While deterring teenagers from vaping may seem like a step in the right direction, many public health researchers worry that such a move could do more harm than good.
Nearly two-thirds of US adults perceive e-cigarettes as either more harmful or just as harmful as combustible cigarettes, according to survey results published this month by the American Cancer Society. Only 11 per cent believe e-cigarettes are less harmful.
While there is much we still don’t know about the potential risks of vapes, one thing is increasingly clear: “Vaping is dramatically better than cigarettes,” says Lynn Kozlowski at the University at Buffalo in New York.
Hyping the harms of e-cigarettes or banning the types of flavours that may broaden their appeal could seriously undermine their potential as tools to help people stop smoking. “As long as smokers believe that vaping is as dangerous or more dangerous than smoking, many of them are never going to try vaping to quit smoking,” says Kenneth Warner at the University of Michigan.
How will the FDA regulate vapes?
On 14 April, a new law went into effect granting the US Food and Drug Administration (FDA) the authority to regulate all vape and e-cigarette products. Before that, the agency could only regulate products containing tobacco-derived nicotine. For those products, the FDA decided in January 2020 to prohibit all flavours except tobacco and menthol, citing evidence that these were the least likely to appeal to adolescents. Given such past decisions, the FDA is expected to further restrict the sale of flavoured e-cigarettes.
“I think with flavours, you could be throwing out an attraction that would reduce the number of adult smokers that would switch to these products,” says Kozlowski. “That trade-off needs to be thoughtfully considered.”
Countries across the globe have weighed this trade-off differently. Some, like India and Thailand, have banned e-cigarettes altogether. Flavoured e-cigarettes can be sold in the EU, but manufacturers must abide by laws restricting nicotine content.
However, in the UK, instead of restricting access, authorities deliberately attempt to make flavoured e-cigarettes attractive and accessible to current smokers. They hope vapes will provide an alternative to cigarettes for smokers looking to quit, says Joanna Cohen at Johns Hopkins University in Maryland.
Which is safer – vaping or smoking?
Several studies now suggest that vaping can indeed help adult smokers quit, including during pregnancy. A 2019 study of 886 cigarette smokers in the UK who were trying to quit found that 18 per cent of those who used e-cigarettes still weren’t smoking one year later, compared with 9.9 per cent of those using a nicotine-replacement therapy like patches or gum. Of the e-cigarette users that quit smoking, 80 per cent still vaped after a year.
While swapping vapes for cigarettes could pose unknown health risks, it significantly reduces exposure to toxins and cancer-causing compounds. A 2018 review by the US National Academies of Sciences, Engineering, and Medicine found that switching to e-cigarettes led to significant improvements in lung, cardiovascular and oral health.
“I view it as an urgent matter for people to get off cigarettes completely. Then, as a secondary goal, they can eventually give up vaping,” says Kozlowski.
The trouble is, when it comes to the health of adolescents, authorities aren’t necessarily weighing the difference between smoking and vaping, but between vaping and not vaping. Right now, pinning down the true potential harms of e-cigarettes is tricky – for several reasons.
How harmful are e-cigarettes?
To begin with, we still don’t know the long-term impact of breathing in the chemicals from vapes. The first e-cigarettes were only introduced to the US and Europe in 2006.
“The solution that people are inhaling is usually a propylene glycol vegetable glycerine mixture, and even though those compounds are regarded as safe for ingestion, we don’t know much about inhaling them,” says Cohen.
Understanding the health consequences of vaping is also complicated by the sheer variety of products, each of which may contain unique chemicals, she says.
It isn’t clear how many of those are harmful. Some, like formaldehyde and acrolein, can damage DNA. Theoretically, this could increase the risk of cancer in the long term, but it isn’t known whether vaping leads to high enough exposures to cause these effects. Unlike with smoking, we don’t yet have decades of observational research to draw on.
Still, what we do know is enough to worry some health authorities. A 2014 study found that, while cigarettes expose people to 10 times more particles than vaping, vapes emit higher amounts of certain metals, like nickel and silver. The risk of inhaling metals is a large part of the US Department of Health and Human Services’ ad campaign against vapes. Chronic inhalation of these metals can cause lung inflammation and conditions like asthma and bronchitis.
Some vapes also contain diacetyl, a food additive with a buttery flavour, says Cohen. Inhaling diacetyl can damage small airways in the lungs, leading to a rare respiratory condition called bronchiolitis obliterans or “popcorn lung”. (Many popcorn manufacturers removed diacetyl from their products after it was linked to hundreds of cases in factory workers.)
Vaping also appears to worsen asthma, bronchitis and coughs in young people, probably due to chemicals irritating the lungs. It also increases the risk of nicotine addiction. Many organisations, including the US Centers for Disease Control and Prevention (CDC), claim nicotine harms adolescent brain development, but most evidence of this comes from animal studies.
How big of a problem is youth vaping?
In the UK, where tobacco products can be purchased from the age of 18, balancing the potential harms to teenagers against the benefits for older smokers is more straightforward: vaping rates among UK adolescents have remained steady in recent years, at about 5 per cent. That is probably due to stricter regulation of e-cigarette adverts compared with the US, says Cohen. E-cigarettes cannot be marketed in newspapers, magazines or online media, per guidelines established by the UK government in 2017. Outdoor billboards and posters are still permitted.
In the US, where the age at which tobacco products can be purchased is now 21, about 11 per cent of high school students report using e-cigarettes in the past 30 days, according to CDC data from October 2021. That is down from a peak of 27 per cent in 2019.
While tobacco advertising is limited in the US — ads can’t be shown on TV or target individuals under 18 — it isn’t banned. Until recently, e-cigarettes were also exempt from these laws as they weren’t considered tobacco products.
Before e-cigarettes became so popular, nicotine use in the US was declining. In 1999, high schoolers reported using nicotine products an average of 5.6 days a month. In 2017, that figure had fallen to 2.2 days a month. By 2019, that number rose to 4.6 — solely due to e-cigarette use — before slightly decreasing again in 2020. A similar trend was observed in middle schoolers.
“One of the number one reasons kids report using [e-cigarettes] is that they like the flavour,” says Cohen. A 2016 study found that teenagers between the ages of 13 and 17 said they were more likely to try fruit-flavoured e-cigarettes compared with menthol or tobacco flavours. Of the more than 2 million US high school and middle school students who reported using e-cigarettes in the past 30 days, almost 85 per cent said they use flavoured products.
Restricting sales of flavoured e-cigarette products will undoubtedly reduce their use among adolescents, but it will also cut their use among adults, says Warner. “We have good evidence that adults like the same flavour categories as kids. The favourite flavour [category] for both groups is fruit. Sweets are the second favourite,” he says.
Most kids who vape do so infrequently or for a short period of time, says Warner. Frequent vaping is more common among students who are current or former smokers, in which case, switching to e-cigarettes would probably improve their health too, says Kozlowski.
“I don’t want any kids using any nicotine product,” says Warner. “But my concern is that we as a nation focus so heavily on the risk for kids that we are ignoring the people who are dying of smoking today.”
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