Sometimes the most important evidence in a public health debate come from the most important informants: the people who are actually affected by public health policy and who know what is happening on the ground. This morning, WGBH reported that the Massachusetts e-cigarette ban is leading youth to substitute real cigarettes or illegal THC vapes for their flavored e-cigarettes.
As the article reports: "Some students say the ban did little to stop use of e-cigarettes and they want to be part of the solution. Sullivan [a youth] says the temporary ban was actually harmful to students:
“It’s forcing students to buy rip-off products, which are even worse for
them, and can be laced.” She added that, with no flavored pods
available for purchase, other students turned to combustible cigarettes,
and even marijuana. “Even if it’s not safe, they'll still get
their hands on it, just because they want to — or they need to, if
they're addicted,” Sullivan said."
The Rest of the Story
This is one high school student who has a promising career in public health if she is interested. She demonstrates more wisdom than many policy makers who have taken on this issue. It is prescient of her to recognize that when you have a product that is under very high demand and particularly if it is addictive, banning it is not going to stop people from using it. But it is going to change the source of these products and the type of products they use. And in the case of banning flavored e-cigarettes, it is going to shift youth away from flavored nicotine e-liquids and towards either black market THC e-liquids or real cigarettes.
While flavored e-cigarette bans may reduce use of these products among youth who only use e-cigarettes occasionally, it is unlikely to substantially reduce vaping among heavy e-cigarette users. However, it will likely create a shift towards more combustible cigarette consumption and more THC vaping, which is especially dangerous (and much more dangerous than e-cigarette use). After all, THC vaping is what has put more than 2,400 people in the hospital with respiratory failure and resulted in 52 deaths. E-cigarettes have not killed any youth or gotten them sick, although it has gotten many youth addicted.
However, there are five key points to understand, related to the fact that among the youth who are heavy users of electronic cigarettes, the majority of them are also experimenting with real cigarettes and with THC vaping:
1. Based on data from the 2018 National Youth Tobacco Survey, two-thirds (67%) of youth who are regular vapers (more than 19 days of use per month) have experimented with THC vaping.
2. Nearly half (48%) of youth who are regular vapers are current smokers.
3. Moreover, 76% of these youth have experimented with cigarette smoking.
4. Among youth who are regular vapers, a whopping 88% have experimented with either THC or cigarettes.
5. Finally, among youth who are regular vapers, a whopping 93% have experimented with THC, cigarettes, cigars, cigarillos, or smokeless tobacco.
What public policy makers who are supporting flavored e-cigarette bans apparently fail to realize is that the overwhelming majority of youth who are using e-cigarettes regularly are kids who are not only puffing on e-cigarettes, but also experimenting with more dangerous substances, including vaped marijuana and tobacco cigarettes.
In this context, it is quite clear that the response to a ban on flavored e-cigarettes among these regular youth vapers is not going to be the total cessation of substance use. Instead, a flavor ban will merely shift what substance they experiment with and use. Most likely, these youth will simply shift toward greater use of THC vapes, real cigarettes, and other tobacco products.
The great irony is that while many anti-tobacco groups claim that e-cigarettes have undermined decades of progress in reducing youth tobacco use, the reality is that bans on flavored e-cigarette use are what will actually undermine our progress in reducing youth tobacco use. And at the same time, they will result in more youth using black market products such as THC vape carts, putting them at a real risk of severe illness.