Thursday, February 22, 2024

Commenting on Flavor Bans: What Should You Discuss?


Flavor bans are probably the most common current threat to vaping in states and municipalities—and next year we’ll probably see more of them. Usually they’re laws passed by state legislatures or city councils. Sometimes, as with the Rhode Island flavor ban or the currently proposed Michigan flavor ban, they’re presented as health department rules.

CASAA does a great job of alerting vapers to threats in states and local governments [disclosure: I’m on the CASAA board], and CASAA chief executive Alex Clark writes terrific responses that you can send to your state or local officials. What could be better than sending CASAA’s well-written takedown of a proposed law, and signing your name to it?

Better would be adding something uniquely yours to the prewritten response, or even replacing the prewritten text altogether and sending your own complete comment. An individual response stands out in a legislator or regulator’s office. It may get attention when a stack of duplicate comments doesn’t (although in some cases, simply flooding the office with opposition letters—no matter what they say—can be the most important thing).

While doing research for my own comment on the proposed Michigan flavor ban, I decided to offer some general suggestions for others making comments on the Michigan ban—or any other flavor ban. This is not by any means all the topics you could write about; it’s just the outline I used for my comments. There are many other ways you might approach the issues.

Depending on how much time you have, you might just want to address one or two aspects of a flavor ban. Or you might choose to get into topics I haven’t even mentioned. Below my suggested talking points, I added a list of academic papers and non-academic articles to draw from when making comments on flavors and related topics. I recommend these resources for additional topic ideas. I hope this helps others organize their own ideas. (Note: please don’t copy/paste my exact words or cite Vaping360 as a scientific source!)

Farsalinos K, Russell C, Lagoumintzis G, Poulas K.
Patterns of flavored e-cigarette use among adults vapers in the United States: an internet survey.
Submission to FDA Docket No. FDA-2017-N-6565 for “Regulation of Flavors in Tobacco Products,” 2018.

The second major survey (2018) of American vapers was submitted as a comment to the FDA, with careful analysis by Dr. Farsalinos. The survey measured the preferences of more than 69,000 adult vapers.

The survey showed that among vapers who had successfully quit smoking, just 7.7% were current users of tobacco-flavored vaping products, but 83.2% used fruit flavors, 72.3% used dessert flavors, 47.7% used candy flavors, and 40.3% used beverage flavors. Many vapers switch between multiple flavors

Russell C, McKeganey N, Dickson T, Nides M.
Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA.
Harm Reduction Journal, 2018.

The first major survey (2016) of U.S. vapers looked at the flavor preferences of more than 20,000 frequent vapers. (The paper was published in 2018—after the Farsalinos survey—but this survey was completed first.)

CONCLUSION: “Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.”

Warner KE, Mendez D.
E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation.

Nicotine and Tobacco Research, 2018.

Two respected University of Michigan tobacco control researchers modeled the number of life-years gained or lost under a variety of circumstances to assess whether vaping uptake among young people will have a net benefit or a net loss to public health.

“Results: With base-case assumptions, the population gains almost 3.3 million life-years by 2070. If all people who quit smoking by vaping lose 10% of the benefit of quitting smoking, the net life-year gain falls to 2.4 million. Under worst-case assumptions, in which vaping increases smoking initiation by 6% and cessation by 5%, and vaping-induced quitters lose 10% of the health benefits, the population gains over 580000 life-years.

“Conclusion: “Potential life-years gained as a result of vaping-induced smoking cessation are projected to exceed potential life-years lost due to vaping-induced smoking initiation. These results hold over a wide range of plausible parameters.

“Implications: Our analysis strongly suggests that the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators. Public messaging and policy should continue to strive to reduce young people’s exposure to all nicotine and tobacco products. But, they should not do so at the expense of limiting such products’ potential to help adult smokers to quit.”

Wang TW, Gentzke AS, Creamer MR, Cullen KA, Holder-Hayes E, Sawdey MD, et al.
Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019.

CDC Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries – December 6, 2019.

TABLE 5. Reasons for e-cigarette use* among middle and high school students who reported ever using e-cigarettes,† by school level, sex, and race/ethnicity.
National Youth Tobacco Survey, United States, 2019. [Table from CDC paper above.]

CDC analysis of the 2019 National Youth Tobacco Survey shows that middle- and high school students who vape do not do it primarily because of flavors.

The question allowed multiple reasons to be listed, but only 22.3% of youth vapers chose “They are available in flavors, such as mint, candy, fruit, or chocolate” as a reason for vaping. The most popular reason (56.1%) was curiosity, and the second-most cited reason (23.9%) was “friend or family member used them.” Nearly as many (21%) selected harm reduction reasons for vaping—”They are less harmful than other forms of tobacco, such as cigarettes” and “To try to quit using other tobacco products, such as cigarettes”—as selected flavors.

Fairchild A, Healton C, Curran J, Abrams D, Bayer R.
Evidence, alarm, and the debate over e-cigarettes.

Science, 2019.

Five well-known public health academics—including three deans of American schools of public health—hash out the pros and cons of vaping, and come down on the side of a well-regulated market that includes flavored products.

“We share strong concern about the large surge in youth vaping (some call it an epidemic and point to studies of a possible but unproven causal gateway into smoking) and we promote harm minimization and management. Yet we suggest that careful analysis of all the data in context indicates that the net benefits of vaped nicotine products outweigh the feared harms to youth.”

“Vaping flavors with or without nicotine may appeal to youth, but flavors also appeal to adult smokers and help them switch. Evidence suggests that the vast majority of smokers who successfully switch completely from smoking combustible products to vaping do so—after weeks, months, or years of dual use—by transitioning from vaping tobacco, or menthol flavored liquids, to other flavors and often to lower nicotine concentrations or even to no nicotine in order to reduce the triggers that remind them of their prior smoking product.”

Glasser AM, Johnson AL, Niaura RS, Abrams DB, Pearson JL.
Youth Vaping and Tobacco Use in Context in the United States: Results from the 2018 National Youth Tobacco Survey.

Nicotine and Tobacco Research, 2020.

Analysis of 2018 National Youth Tobacco Survey, in which well-known tobacco control researchers break down the eye-popping “past-30-day” use number, and find that very few youth vapers are doing anything but experimenting. Most teen vapers had used other tobacco products already, and of the small number that hadn’t, only a tiny fraction were frequent vapers.

“Implications: Results underscore the importance of including the full context of use patterns. The majority of vapers (60.0%–88.9% by use frequency) were concurrent p30d or ever tobacco users. About 4% of students were tobacco naïve and vaped in the p30d, but few (0.4%) vaped regularly on 20 or more days. Reporting youth vaping data with frequency and tobacco product co-use will give public health decision-makers the best possible information to protect public health.”

Du P, Bascom R, Fan T, Sinharoy A, Yingst J, Mondal P, Foulds J.
Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users.

Annals of the American Thoracic Society, 2020.

Adult e-cigarette users surveyed by Penn State University in 2012-14 were re-surveyed in 2017 to assess changes in their vaping preferences, including flavor preferences. Most tobacco-, menthol- and mint-flavored users migrated to other flavors.

Results: “Participants’ age averaged 44 ± 12 years; 86% were exclusive e-cigarette users, and 13% reported “poly-use” (i.e., e-cigarette and other tobacco product use). E-cigarette flavor preference migration occurred in all demographic groups: only 36–44% maintained a preference for their original flavor. Preference for tobacco and menthol or mint decreased over time (40% baseline vs. 22% follow-up); preference for fruit remained stable (23% baseline and follow-up), but chocolate/candy or other sweets preference significantly increased (16% baseline vs. 29% follow-up), and other flavors increased slightly. Migration to sweet flavors was more noticeable in younger adults (18–45 yr); exclusive e-cigarette users preferred sweet flavors more commonly than poly-users did (31% vs. 19%). Flavor-associated adverse reactions, mainly respiratory irritations, were reported by 26 (6.9%) participants. Nearly 50% of the participants reported that they would “find a way” to buy their preferred flavor or add flavoring agents themselves if nontobacco flavors were banned.”

Yang Y, Lindblon EN, Salloum RG, Warda KD.
The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults.

Addictive Behaviors Reports, 2020.

Small survey of tobacco users in San Francisco after that city’s first-in-country 2019 flavor ban. The researchers found that banning flavors does reduce vaping. It also increases cigarette smoking.

“Conclusions: These findings suggest that comprehensive local flavor bans, by themselves, cannot sharply reduce the availability or use of flavored tobacco products among residents. Nevertheless, local bans can still significantly reduce overall e-cigarette use and cigar smoking but may increase cigarette smoking.”

Friedman AS, Xu S.
Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation.

JAMA Network Open, 2020.

Two Yale researchers analyzed longitudinal survey data from the FDA Population Assessment of Tobacco and Health (PATH) study (collected from 2013 to 2018). The goal was to discover whether uptake of flavored vaping products was associated with smoking initiation in youth or cessation in adults.

Conclusion: “In this study, adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors. More research is needed to establish the relationship between e-cigarette flavors and smoking and to guide related policy.”

Gravely S, Cummings KM, Hammond D, Lindblom E, Smith DM, Martin N, et al.
The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

Nicotine and Tobacco Research, 2020.

A group of highly respected American, Canadian and Australian tobacco control researchers recently studied flavor preferences among vapers. They found that a majority of frequent vapers prefer non-tobacco flavors.

CONCLUSION: “A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.”

Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA.
E-cigarette Use Among Middle and High School Students — United States, 2020
CDC Morbidity and Mortality Weekly Report (MMWR), September 18, 2020.

The 2020 National Youth Tobacco Survey shows that vaping among middle- and high school students dropped 29% since last year—from 27.5% to 19.6%.

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