“It’s pretty trendy right now. The flavors are crazy.”
“I started with mango because it seemed pretty good.”
“Kids do it in the bathroom, in between classes, and at lunch. Pretty much all time.”
These are actual comments from a few of my teenage patients — they love the flavors of e-cigarettes. The teens I speak to try e-cigarettes out of curiosity and to follow a trend, not because they are ex-cigarette smokers, looking for an alternative. That's a problem.
Earlier in October, JUUL announced that it was suspending sales of its fruity e-cigarette flavors, like mango, as the Trump administration and various states look into various bans. This is a potentially positive step on JUUL’s part, although it doesn’t stop other companies from selling their own flavored pods.
Meanwhile, the scientific community is being accused of creating a bit of hysteria around the issue of e-cigarettes. It's true that banning e-cigs while allowing traditional cigarettes to stay on drugstore shelves seems unproductive. But there is a real reason for urgency where vaping is concerned. Vaping related illnesses — many but not all of which are linked to THC-containing pods — seem to be increasing by the day. Moreover, we know nicotine is a highly addictive substance and detrimental to the developing adolescent brain, a process which continues until the mid-20s.
We need a multifaceted approach to both make sure e-cigarettes are properly regulated and to make sure we are not creating a generation of nicotine-addicted teens. And while I agree with several of The Vapor Technology Association’s 11 steps to limiting youth vaping, I still feel limiting flavors is an obvious first step. Vaping advocates, such as the VTA, vehemently stand against a flavor ban citing two factors: the livelihood of vape shops and the necessary options for adults who are trying to quit. But those arguments may simply not be enough, given that e-cigarette usage among high schoolers increased by 78 percent between 2017 and 2018.
Clearly, however, any compromise on e-cigarettes can’t happen without some understanding of the desires of adult vapers. The American Vaping Association recently called me a “smug and misinformed doctor,” so for the past few weeks, I've set out to become “vaping-woke.” On Twitter, I read countless personal stories, from thousands of ex-cigarette smokers. One even shared a chest X-ray online celebrating the fact that he felt he could breathe better after switching from traditional cigarettes to the electronic version.
Millions of adult smokers obviously feel marginalized. And if we were discussing an overall ban on vaping, I would agree with that sentiment. But for the sake of this argument, let’s focus on the problem specifically with flavored vapes.
Adult vapors appreciate flavors in the same way anyone would appreciate variety in a frozen-yogurt store. But also not surprisingly, flavors appeal the most to younger users. Data from the national longitudinal Population Assessment of Tobacco and Health (PATH) study, show that 85 percent of current e-cigarette users ages 12–17 use flavored versions of e-cigarettes compared to 63 percent of adults ages 25 and older.
The differentiation lies in motivation. Adults users, as advertised by the industry, turn to e-cigarettes to transition away from combustible tobacco. On the other hand, a majority of teens and even adults with no previous smoking history are attracted foremost by the flavors.
On this note, one has to wonder if adult smokers who are serious about transitioning sincerely need flavor options such as “unicorn puke,” “sweet tarts” and “crème brulee” in order to make the leap. These flavors may help, but there has to be a trade-off given what we know motivates youths to try vaping.
I actually agree with that an outright-ban of vaping may have unintended consequences — also, it will be ironic if e-cigarettes are banned while traditional cigarettes were still widely sold. Cigarettes kill roughly 480,000 Americans annually and 7-million worldwide. It goes without saying that reducing this number is a vital goal. If a regulated e-cigarette industry for adults can help achieve that, great. Nonetheless, keeping the variety of flavors falls into a tricky paradigm of creating a product that reportedly helps one demographic while ignoring the consequences of another.
The VTA warned that if “if a federal flavor ban is enacted, more than 10 million adults will be forced to choose between smoking again [...] or finding what they want on the black market.” Unregulated black-market liquids could absolutely be dangerous, as could the results from DIY experiments led by threads on Reddit. (And by the way, a black market already exists and is likely to only grow in time with increased regulation. But it doesn’t seem feasible to avoid tackling an important public health problem because of vague “black market” fears.)
Similar to what we’ve seen with opioids and illicit drugs, any regulation could theoretically lead to more black-market activity and most vaping activists agree on increased regulations to curb teen use. Several have endorsed proactive measures like raising the purchase age to 21, electronic scanning technology to verify thepurchaser’s age, limitations on how much retailers can sell, regulating online sales, harsher penalties for any retailer selling to minors, and more.
If we turn our focus to how a flavor ban would affect the tens of thousands of vape shops across the country, it becomes a more convoluted issue. Amidst proposals from several states to ban flavored vaping products, there is nationwide panic and an interesting clash between economics and public health.
Time will tell how this plays out, but it’s readily apparent that political pressure will play a central role in the debate, especially considering how a Michigan state judge recently stopped a flavored vaping ban. The Los Angeles Times exclusively reported that the FDA tried to ban vaping flavors, years ago, but pressure from the tobacco and vaping industry derailed the effort.
I would be hard-pressed to find any physician who would be apathetic about the prospect of thousands of small businesses closing. But many public health debates, from gun control to prescription drug pricing to reproductive rights, come with economic and political variables.
A 16-year-old hospitalized teen once showed me videos of a YouTuber, with nearly 3 million subscribers, doing vape tricks. He admitted he tried vaping too and I asked if he was motivated by the impressive “vape bubble tricks.”
He told me he was more interested in the flavors he kept hearing about at school.
The vaping industry indirectly asked me to chat with adult smokers. Now I would ask them to talk with teen vapers. Infamous buzzwords such as “safer alternative” helped created a world where many teens believe e-cigarettes are harmless or do not even contain nicotine. A recent survey showed 39 percent of high school students believed JUUL were not e-cigarettes or were unsure.
While the vaping community stands by electronic nicotine delivery systems’ potential to help adult smokers, we have to face reality that they present an enticing set-up for teen experimentation.
We need to act now, by targeting the factors that lure teens to vaping in the first place. The unknown long-term sequelae of exposing millions of developing brains to nicotine should be more than enough to end the vaping-flavor debate.