The True Impact of an E-liquid Flavour Ban

Activists were pressuring for a ban on flavoured vapes, claiming it encouraged teen vaping and that, in turn, led to smoking. When states or cities implemented their own bans, researchers have been able to compare what happened with neighbouring districts. The sad fact is that advocates and harm reduction experts were correct, bans on the e-liquid flavours favoured by adult ex-smokers led to an increase in smoking rates. President Trump announced that the United States Food and Drug Administration would develop a plan to ban nearly all flavoured e-cigarettes, in 2019. This federal action stuttered, but individual states implemented their own bans on flavoured e-liquids in the meantime. Speaking to a subcommittee, Matthew Myers, president of the Campaign for Tobacco-Free Kids told politicians: " The use of sweet flavours, youth-friendly marketing, and easy access have led to skyrocketing levels of youth e-cigarette use ." New York, state Rep. Linda Rosenthal, Democrat, typifies an additional point of view based on emotion: " Somehow, I just knew. At the time, most e-cigarettes were made in China and no one knew what was in them. We should know what's in a product before we put it into our bodies. Selling poisons to kids isn't a very good business model ." Essentially, the entire argument behind banning flavoured juices is protecting children from nicotine addiction, that vaping is " poison ", and is needed to address an " epidemic " of vaping. The idea behind a ban is that it would reap the same rewards as the ban on flavoured tobacco products. A study published in 2020 concluded: " The US cigarette flavour ban to menthol products would promote smoking cessation and reduce initiation. This evidence supports further action by the FDA towards mentholated tobacco products. However, few studies have been conducted in the vaping era ." The approach appears logical; if a teen vaping epidemic exists then removing popular flavoured products leaves them nothing to use and ought to drive down usage rates. But is it this simple? To answer this, we first need to look at whether there is a problem in the first place. Although referring to the United Kingdom, in 2019, Dr Lion Shahab from University College London explained that vaping is a disruptive tool that prevented teens from experimenting with cigarettes. He explained to the Daily Mirror that, consequently, exposure to the toxins contained in cigarette smoke was reduced by 95% in those who vape instead of smoke. He added that using an electronic cigarette was as dangerous as using traditional nicotine replacement therapies such as sprays, patches, or gums. " If you inhale something into your lungs it is likely to cause some irritation and increase the risk of some diseases. I would not recommend anyone who's never smoked to start vaping. But it's complicated with adolescents. Some of them who pick up an e-cigarette will not then go on to try a cigarette ," he told the tabloid. US studies tend to focus on ever having tried a vape which skews the results to make vaping look exceptionally prevalent. Another team from University College London looked at this last year and the results were published in January 2021. They noted that although there had been a rise in teen vaping, it was directly linked to a dramatic decline in teen smoking rates. They also pointed out that teens who used e-cigs were less dependent on nicotine compared to smokers and that vaping offered a fraction of the risk of tobacco use. A picture is now emerging that vaping works as an intervention tool, offers a reduction in harm, and is not as addictive as smoking. So, what of the American teen " epidemic "? University College London Professors Jarvis, Jackson, West, and Brown answered this question in 2020. In their study, they concluded: " While use of e-cigarettes in US high-school students increased sharply between 2017 and 2019, frequent use and signs of e-cigarette dependence remained rare in students who had only ever used e-cigarettes and never any other tobacco product ." " In 2019, high school students who had smoked more than 100 cigarettes in their lifetime were some 18 times more likely to have used e-cigarettes in the past 30 days than students who had only ever used e-cigarettes and never other tobacco products. In 2018, use of e-cigarettes on 20 or more days in the past month was seen in only 1.0% of those who were otherwise tobacco naive and in 2019 the figure was only 2.1% ." " 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 . We found little evidence of substantial nicotine addiction attributable to the use of e-cigarettes ." By this stage it is becoming clear that not only are efforts to ban vaping and flavoured e-liquids misguided because they ignore the benefits of a harm reduction approach, but there is also no teen epidemic to be concerned about. Even ' ever-use ', the figure loved by the likes of Matthew Myers is in dramatic decline. See this tweet from harm reduction expert Clive Bates, posted this October (2021) following figures released from the Centres for Disease Control and Prevention and the Food and Drug Administration showing a drop in use for the second consecutive year. The question at this point might be, ' If evidence is here to show that vaping works, reduces harm, and doesn't cause an issue with teen use, why are people persisting with the claim that something needs to be done ?' The short answer is that some are ideologically opposed to nicotine use because they link this to the tobacco industry and that states are seeing declining revenues from tobacco sales. The latter is because the states took out big loans linked to their anticipated income from the Tobacco Master Settlement Agreement ( TMSA ). The TMSA promised a regular income, but vaping has reduced cigarette sales and states " have borrowed more than $4 billion against settlement money that might never materialise ." It is in their financial interest to keep people smoking. What has been the impact of banning flavoured e-liquid? While the American Government failed to make its mind up whether it should institute a ban on flavoured e-liquid, individual states took their own steps. The state of Massachusetts banned all flavours other than tobacco, as did cities such as San Francisco. Such action has raised the spectre of unintended consequences. In one study, " 33.2% [of youth ecig users] were likely to switch to cigarettes " if they faced a ban on flavoured products. Reactions to Sales Restrictions on Flavoured Vape Products Findings:

• 2% of e-cigarette users supported (strongly/somewhat) sales restrictions on flavoured vape products
• 6% of nonusers supported (strongly/somewhat) sales restrictions on flavoured vape products
• 1% of e-cigarette users supported complete vape product sales restrictions
• 1% of nonusers supported complete vape product sales restrictions

• If restricted to tobacco flavours, 39.1% of e-cigarette users reported being likely (very/somewhat) to continue using e-cigarettes
• If restricted to tobacco flavours, 30.5% of e-cigarette users reported being not at all likely to continue using e-cigarettes
• If restricted to tobacco flavours, 33.2% of e-cigarette users reported they were likely to switch to cigarettes
• Facing a complete ban on all vape products, 39% were likely to switch to cigarettes

What would happen was being made clear to legislators. Dr Charles Gardner, the executive director of INNCO, a global non-profit, told Filter Magazine: " The FDA must know flavour bans will increase teen, young adult, and older adult smoking ." Forbes Magazine wrote: " Early results from the flavoured tobacco & vaping products prohibition enacted in Massachusetts show such bans deprive adults of less harmful alternatives to cigarettes, crush small businesses, depress tax collections as commerce shifts across state lines, and fail to curb smoking ." What does research tell us about the impact of these bans? In a study conducted by the School of Public Health at the University of Memphis in conjunction with the Department of Health Outcomes and Policy at the University of Florida, researchers found: " Comprehensive local flavour bans, by themselves, cannot sharply reduce the availability or use of flavoured tobacco products among residents. Nevertheless, local bans can still significantly reduce overall e-cigarette use and cigar smoking but may increase cigarette smoking ." After the San Francisco ban, University of Memphis Findings:

• 66% of participants did not support the ban
• 65% believed the ban had not been enforced completely

• 3% of only-vape nicotine users continued to vape
• 7% of only-vape nicotine users quit using all products
• 19% of only-vape nicotine users returned to smoking tobacco products

• 4% of dual users (smoke and vape) continued to use ecigs
• 7% of dual users (smoke and vape) quit all nicotine products
• 9% of dual users (smoke and vape) stopped vaping and continued to smoke tobacco only

Most users in the University of Memphis study reported being able to obtain flavoured products in multiple ways despite the ban - either from shops supplying products illegally or importing them from neighbouring regions online. Researchers at the Yale School of Public Health looked at the impact of the San Francisco flavour ban. The Yale study analysed data from the Youth Risk Behaviour Surveillance System biennial school district surveys, with consideration restricted to districts with representative smoking data (with response rates 60%) available through the US Centres for Disease Control and Prevention The study found that San Francisco's ban on flavoured products " was associated with increased smoking " in school children when compared to nearby school districts in areas without a ban in place. " This raises concerns that reducing access to flavoured electronic nicotine delivery systems may motivate youths [to smoke] who would otherwise vape to substitute smoking. " Lead author Abigail Friedman said: " These findings suggest a need for caution. While neither smoking cigarettes nor vaping nicotine are safe per se, the bulk of current evidence indicates substantially greater harms from smoking, which is responsible for nearly one in five adult deaths annually. Even if it is well-intentioned, a law that increases youth smoking could pose a threat to public health ." After the San Francisco ban, Yale University Findings:

• Initial data covered 100,695 minors
• 95,843 had complete data on recent smoking habits

• Among those with data, 9,225 respondents came from San Francisco
• 86,618 respondents came from districts without flavour bans

• Smoking rate of 6.2% was noted in San Francisco after the ban
• Smoking rate of 2.8% was noted in other districts

• " San Francisco's flavour ban was associated with more than doubled odds of recent smoking among underage high school students relative to concurrent changes in other districts "

Then, in September 2021, the Food and Drug Administration effectively banned flavoured e-liquid this year by denying companies the authorisation to sell products. In one fell swoop it effectively banned more 55,000 flavoured e-cigarette products. The impact was instant. An article on Politico highlighted: " Small- and medium-sized e-cigarette makers and vendors are fighting to keep their doors open after the Food and Drug Administration ordered them to stop selling more than 6 million flavoured vapes ." Banning flavours hits jobs, company profits, and (most importantly) the ability of informed adult smokers to switch and reduce their harm exposure. The article quotes a senior tobacco industry official who requested anonymity: " The agency took a big step backwards in harm reduction. If there's no one who has a flavoured product that can get through, people are going to be less likely to switch ". Conclusion: The argument for banning flavoured vapes relies upon the argument that there is a problem with teens taking up vaping, that the numbers doing so is at a high level, and that removing these products from the marketplace will prevent them using any form of nicotine. We have demonstrated that not only is there no such epidemic of teen vaping, but that banning flavoured products comes with unintended consequences: businesses fold, jobs are lost, teens take up smoking and adult smokers are denied the very products that help them switch away from tobacco. While it ought to be clear that legislators should rely on facts and evidence, this quote from an article in Forbes Magazine warns: " Just because a policy has already been documented to be a proven failure doesn't mean politicians will cease proposing it ."