Tuesday, November 26, 2019

Why E-Cigarette Flavor Bans are Misguided: The Flavor's Not the Problem, It's the Nicotine Salts

The obsession of policy makers, politicians, and health groups on banning flavored e-cigarettes as a solution to the youth vaping epidemic is misguided and is detracting attention from the real issue: the use of nicotine salts that have greatly increased the addiction potential of e-cigarettes.

Prior to the introduction of JUUL, three-fourths (74%) of nonsmoking youth e-cigarette users reported using e-cigarettes no more than about once a week and only 4% used them every day, a sure sign of addiction. But by 2018, 12% of nonsmoking youth vapers used e-cigarettes every day, a tripling of the percentage of youth e-cigarette users who were addicted, and less than half (42%) of non-smoking youth e-cigarette users only used them less than once a week. 

This change is what has created a public health crisis. So what explains this change?  

Was it the introduction of flavors?

Absolutely not. Back in 2015, there were just as many flavors on the market as there are now. There were plenty of sweet, fruity, candy flavors available. If anything, JUUL offered fewer flavors than most other e-cigarettes. 

What changed is that JUUL discovered that if you use a nicotine salt to deliver the nicotine rather than freebase nicotine, it is absorbed into the bloodstream much more rapidly. The upshot of this is that the product delivers a nicotine hit or buzz, unlike virtually all other e-cigarettes on the market. 

So when products like JUUL, Suorin, SMOK, and Phix entered the market with their nicotine salts, they quickly became popular among teenagers. All of these brands use a different nicotine formulation from virtually all other e-cigarettes. They use a nicotine salt at very high concentrations, as much as 50 mg/mL, compared to most other e-cigarettes on the market, which do not use nicotine salts and generally have nicotine concentrations that are less than 25 mg/mL. The use of nicotine salts allows the nicotine to be absorbed into the bloodstream much more quickly, simulating the pattern you get with a real cigarette. This is why so many youth are now becoming addicted to vaping. It’s not the flavors. It’s the nicotine. And more specifically, it's the nicotine formulation and to some extent, the concentration.

The combination of nicotine salts and high concentrations of nicotine is what changed youth e-cigarette use from a problem to a crisis. It's not the flavors that created this crisis, it's the nicotine absorption pattern of these new products. 

The reality is that prior to JUUL and its copycats, nicotine addiction was not a problem among youth e-cigarette users. Patterns of use were not habitual, but were almost exclusively social. There were plenty of cotton candy e-cigarette available. But e-cigarette use was not a crisis. There were plenty of gummy bear flavors around. But e-cigarette use was not a crisis. Kids weren't getting addicted to cherry, strawberry, or banana vapes. Nicotine salts--not the flavors--changed everything.

And so now, policy makers are deceiving themselves if they think that banning e-cigarette flavors is the answer to this crisis. No - what's going to happen is that many youth are going to switch over to the e-liquids that remain easily accessible: THC vape carts. Yes, the ones that are causing the respiratory disease outbreak that has killed 49 people and sent more than 2,000 to the hospital with respiratory failure. 

It's even possible that many youth will switch over to the tobacco flavors. Not only will they continue to be addicted to nicotine, but then a transition to cigarette smoking will become a real risk, something that is not the case today because a youth is not going to transition from a sweet-flavored e-cigarette to a Marlboro. But switching from a tobacco-flavored JUUL to a Marlboro is probably much more realistic.

So beyond the devastating effects of flavored e-cigarette bans on adult vapers - leading them to return to smoking or to a new, potentially dangerous black market - flavor bans are actually going to make things worse for youth as well, by driving them towards cigarette use or towards black market products that are even more acutely dangerous.

The most effective solution is right before our eyes, but it's being hidden because of the obsessive and misguided focus on cotton candy, bubble gum, and gummy bear. What we need to do is not ban bubble gum flavor, but severely restrict and control the use of nicotine salts as well as limit the allowable nicotine concentrations in all products.

The Rest of the Story

The biggest myth out there is that there is such a thing as an unflavored e-cigarette. There is no such thing. Every e-cigarette (i.e., e-liquid) is flavored. It's just a question of what the flavor is.

This is another reason why arguing that the flavors are the problem is a meaningless statement. Every e-cigarette is flavored, so how can you argue that the flavors are the problem. 

E-cigarette flavor bans, then, are not actually flavor bans. What they are is policy makers dictating to e-liquid manufacturers that they can only produce one flavor out of a list of thousands: tobacco-flavor. 

Even tobacco flavor is not a single flavor. There are many varieties of tobacco flavor on the market: classic tobacco, Virginia tobacco, regular tobacco, golden tobacco, and so on. Youth will find a way to make the tobacco flavors more palatable. Already, they are using mints to accomplish this. Soon they will be buying their own flavorings and adding it to the tobacco e-liquids. At least, youth are aren't exclusively vaping THC will be doing this.

The only effective way to substantially reduce youth access to flavored e-cigarettes would be to ban them completely. Otherwise, there will always continue to be flavored e-cigarettes available. However, a complete ban on e-cigarettes would be even worse for adult smokers and vapers than banning non-tobacco-flavored e-cigarettes (although probably not much worse).

Policy makers who are using the respiratory disease outbreak as a justification for banning e-cigarette flavors are perhaps the most irresponsible of all. If they truly believe that e-cigarettes present a risk of life-threatening respiratory disease, then how can they possibly allow tobacco-flavored e-cigarettes to remain on the market? There is simply no justification for that and by their own admission, they are knowingly putting the lives of youth at risk.

In fact, every public health advocate who has used the respiratory disease outbreak as a justification for the need to ban e-cigarette flavors is acting irresponsibly because by allowing tobacco flavored e-cigarettes to remain, they are knowingly putting the lives of youth at risk for what is essentially political gain.

The real question is really more basic: Do we allow e-cigarettes or do we not allow them? 

The good news is that we can choose the first option while at the same time putting an end to the youth vaping crisis. The sad truth is that the real objective is not to end the youth vaping crisis and to protect youth from the most important risks they face. Instead, it's to get flavors off the market in order to punish e-cigarette companies so that we can feel better about the fact that so many youth are Juuling.

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