Will Restricting Flavour Options Eliminate Youth Uptake of E-cigarettes?

November 03, 2019

Will Restricting Flavour Options Eliminate Youth Uptake of E-cigarettes?

Axios reported on Friday that the Trump administration may move to ban all flavoured e-liquid except for tobacco and menthol as soon as this week. This based on a hunch that restricting flavour options may reduce youth uptake of e-cigarettes. I say hunch because there is no data or real evidence suggesting that this will reduce youth uptake in the least. There are similar rumblings in Canada, with some legislators and public health officials unashamedly stating that their reason for wanting a flavour ban is that they know kids like flavour. That reporters don’t snicker at these statements or throw back the question, “do only kids like flavour?” gives you some indication of where we are at in terms of reasonable debate.

Unfortunately we don’t have good data on the number of young people who vape ‘for the flavour’, it simply hasn’t been collected beyond the anecdotal. We do have data on flavour and tobacco products use in Canada though. According to the Summary of results for the Canadian Student Tobacco, Alcohol and Drugs Survey 2016-17"One third (35%) of students who had used a tobacco product (approximately 153,000) reported that the first tobacco product they used was flavoured. A higher percentage of grade 10 to 12 students (37%) than grade 7 to 9 students (28%) reported that the first tobacco product that they used was flavoured." According to the same survey, 18% of students had smoked. So two thirds of students who reported smoking didn’t care at all about the ashtray taste associated with smoking (at least not enough to dissuade them from smoking) and one third reported smoking a flavoured (so slightly less vile) version at least once during a 30 day period.

Statistics Canada notes that most smokers take up the habit in the their teens (16% 13 years old or younger, 55% between 14 and 17 years of age, 15% 18-19 years old). Indicators for smoking include gender, socioeconomic status, education, major depressive episode, high chronic stress, and low self esteem. The same report notes that, “the majority of smokers start in adolescence, and this affects the amount that they smoke and their chances of quitting in later life. Thus, while preventing smoking initiation altogether is most desirable, delaying it by even a few years might have both individual and public-health benefits.” It is encouraging then, to note that Stats Can most recent survey (Smokers by Age Group, pub 2019) records a decrease in smokers among 12-17 year olds.

Interestingly, while the Summary of results for the Canadian Student Tobacco, Alcohol and Drugs Survey acknowledges that alcohol use is the substance with the highest prevalence of use among students (44%), the question of flavour did not come up. Of the 17% who use cannabis, it’s probably safe to assume that flavour isn’t a driver. If we are indeed looking to shape legislation by hunch, it seems safer to assume that teenagers are the least likely group to be dissuaded from risk-taking behaviours by flavour alone.

While we don’t have data on whether flavour plays a part in youth uptake of e-cigarettes, we do have some evidence of the role it plays in adult consumption. Rights 4 Vapers surveyed almost 4,000 (Canadian) adult vapers with the following results: less than 800 respondents reported using tobacco flavoured e-liquid initially dropping to less than 600 over time, corresponding to data we see from other countries. The longer a smoker has been away from cigarettes, the less likely they are to tolerate tobacco flavours. The most popular flavours (by a long shot) were candy (>1300-2400) and fruit flavours (>1800-2700), both at the start of vaping and over time.

Similarly, 98.6% of 4669 consumers surveyed in the U.S. oppose a flavour ban and 95.9% reported that they would be less likely to vote for a candidate who wanted to restrict flavour choices. That restricting flavour options would influence a person’s vote, especially in a country like the United States where party loyalty tends to be firmly entrenched, tells us something about how important an issue this is to ex-smokers and the role that flavour plays.

The largest survey by far on the role of flavours in e-cigarette use is Patterns of flavored e-cigarette use among adults vapers in the United States authored by Konstantinos Farsalinos, MD, MPH, Christopher Russell, PhD, George Lagoumintzis, PhD, and Konstantinos Poulas. 69,233 adult e-cigarette users living in the United States participated in the survey. Of the respondents, 94.8% previously smoked and the mean age of regular e-cigarette use was 31.2 years old. At the time of e-cigarette use initiation, “The most popular flavors were fruit and dessert/pastry/bakery, while only approximately 20% reported using tobacco flavors.” At the time of participating in the survey, “The most popular flavors were again fruit and dessert/pastry/bakery. Use of tobacco flavors was less prevalent compared to e-cigarette use initiation, which has also been documented in other surveys. In fact, only 2% of participants reported that the single most often used flavor at the time of survey participation was a tobacco flavor. Many participants reported using multiple flavors within the same day.”

The authors conclude that, “this cross-sectional study of a very large sample of adult US e-cigarette users, most of which were former smokers, identified the importance of non-tobacco flavors in ecigarette use initiation and sustained use, and their contribution to smoking cessation and relapse prevention. This information should be considered by regulators in order to avoid unintentional adverse effects of over-restrictive regulation on e-cigarette flavors.”

Understandably, many people (particularly in the U.S.) who quit smoking through vaping are concerned and have taken to online campaigns, rallies, and participation in public hearings. This has been going on for some time but the energy has ramped up considerably in recent months with many seeing vaping under increasing threat and believing this to be an affront to personal liberties and an attack on their right to health and commerce. A massive rally is being planned for November 9th in Washington. 

The response in Canada has been less vocal outside of industry but it is worth noting that we do not have a national consumer advocacy group the likes of CASAA in this country so it is to be expected that consumers are less engaged. Add to which we have, for a time, enjoyed more support from our federal government as it has taken a more deliberative, measured approach to e-cigarette use. Things are ramping up most quickly at the provincial level with legislators in reactive mode and, unfortunately, with recent events in the United States even our federal government appears on the brink of turning.

Returning to the point of whether restricting flavours will have any impact on youth uptake of e-cigarettes. The answer based on the limited evidence that we do have is probably not, not by any substantial amount but it may, possibly, make it slightly less attractive to young people. (Not exactly a ringing endorsement for any proposed legislation that threatens to impact the health of a great number of adults.) It will undoubtedly have an effect on vapers who, lest we forget, are largely comprised of ex-smokers and have indicated that flavour plays a crucial role in their ability to remain tobacco free. And I guess for some people that’s a fair trade. The old, “quit or die,” mentality among legislators and never-smokers remains sadly entrenched.

But if our primary concern is for the children, the very small percentage of young people who have tried vaping without ever having previously smoked, we should consider the consequences of introducing them to tobacco flavour. Because while it is very difficult to find the taste of tobacco appealing in comparison to fruity or dessert flavours, tobacco holds up not badly against tobacco. Even the most vocal of anti-vape activists will concede that eliminating flavours will not completely wipe out youth uptake so what we are proposing doing is normalizing the flavour of tobacco among those young people who will take it up. And, if flavours really are important to some young people they will be able to access flavoured products on the black market that will no doubt arise to fill the gap in the legal market. When accessing prohibited products, legal market access isn’t really a stumbling block among youth. This of course leaves open the potential for the spread of contaminated or otherwise problematic e-liquids reaching both young people and adults.

As for the Canadian government’s tobacco strategy to curb smoking rates to below 5% by 2035, limiting the most successful advance in tobacco harm reduction is in complete contradiction to their acknowledgement that “giving smokers access to less harmful options will help reduce their health risks and possibly save lives.” 

As Adam Thierer points out in a recent article, “No matter how well intentioned, sometimes hyper-precautionary rules can be deadly. By defaulting public policies to super-cautious mode and curtailing important innovations, laws and regulations can actually make the world less safe. ... The dynamic nature of regulatory trade-offs such as these is what makes benefit-cost analysis so challenging yet essential. Policy makers must do a better job trying to model the costs of regulatory decisions- especially those involving sweeping precautionary controls- precisely because the costs of getting things wrong can be so profound.”

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