Four highly regarded tobacco control scholars are calling for a policy agenda on e-cigarettes that balances curbing youth use with promoting vaping products as tools that can help adult smokers switch to safer nicotine alternatives. Their agenda—which consists of making e-cigarettes more easily and cheaply available than cigarettes, but also of reducing cigarettes’ nicotine content and banning a range of flavored vaping and tobacco products—is certain to draw criticism both from anti-nicotine zealots and tobacco harm reduction proponents.
In a short paper appearing in Health Affairs, a leading, peer-reviewed health policy journal, Kenneth Warner, Cliff Douglas and Karalyn Kiessling, all of the University of Michigan, and Alex Liber of Georgetown University acknowledge that many Americans remain confused about the relative harms of nicotine use, and that public messaging around the substance tends to be much more focused on stopping youth use than educating adults. Cigarette smoking remains the number one cause of preventable death in the United States. The authors frame the debate, in part, as “a matter of social justice,” as Black Americans “suffer disproportionately from smoking-related mortality” and “Americans with lower educations and incomes, members of the LGBTQ community, and people with mental health conditions constitute a disproportionate share of the smoking population.”
“We need to find policies that simultaneously address the widely shared dual goals of preventing youth vaping and increasing adult smoking cessation.”
Warner described the article to Filter as an “attempt to seek some middle policy ground regarding e-cigarettes.”
“Policy regarding e-cigarettes in the US has focused on measures intended to reduce youth vaping, including imposing taxes on e-cigarettes and restricting flavors,” Warner told Filter. “Unfortunately, some of the measures may be backfiring. For example, if not matched by at least comparable increases in cigarette taxes, e-cigarette taxes that reduce youth vaping may also increase kids’ smoking. As well, some of these youth-oriented taxes appear to be reducing adult smokers’ use of e-cigarettes, increasing their smoking, and reducing smoking cessation. We need to find policies that simultaneously address the widely shared dual goals of preventing youth vaping and increasing adult smoking cessation.”
“We appeal to colleagues to focus on these two widely shared tobacco control objectives: keeping tobacco and nicotine products permanently out of the hands (and mouths) of US youth and helping as many adults as possible kick their deadly allegiance to combusted tobacco products,” the co-authors write. They choose to focus on the “four Ps,” borrowed from a 1960s textbook meant to help companies with their marketing schemes: product, price, place and promotion.
Among their recommendations, they advocate for the Food and Drug Administration (FDA) to follow through on its plan to reduce the nicotine levels in combustible cigarettes to effectively zero. That is a highly disputed move for many tobacco harm reductionists, some of whom argue that it would encourage people to smoke more to get the same amount of nicotine and foster illicit markets. As the authors note, it is also likely to be met with legal challenges from tobacco manufacturers. They add that it will have the best outcome if “accompanied by regulations ensuring the availability of alternative products, such as e-cigarettes” authorized by the agency.
They state, too, that cigarettes and e-cigarettes are economic substitutes, and, consequently, “states and the federal government should levy large excise taxes on cigarettes and other combustible tobacco products and a more modest excise tax on e-cigarettes.” (Adults, the logic goes, would be more likely to switch to safer alternatives if they were substantially cheaper.)
They insist that governments establish laws that only allow vape and tobacco shops to sell nicotine products, and in another hugely controversial recommendation, suggest prohibiting all flavors in combustible tobacco products, as well as banning “all e-cigarette flavors other than tobacco and menthol and possibly a relatively small selection of other flavors with clearly adult-oriented marketing” that the FDA has deemed “appropriate for the protection of public health”—a standard, now seemingly ubiquitous in tobacco control circles, taken to mean presenting a safer option for adults while not introduing a new generation to nicotine.
Harm reductionists point out that the majority of adults who switch to vaping find that flavors make them more likely to do so.
While prohibition-oriented groups like the Campaign for Tobacco-Free Kids (CTFK) have long pushed for flavor bans, harm reductionists point out that the majority of adults who switch to vaping find that flavors make them more likely to do so. (Some studies have shown that flavor bans have adverse effects, like drawing more teens to smoking.) The FDA, which has authorized just a handful of vaping products from large manufacturers through its constantly under-fire PMTA process, has yet to authorize any flavored products.
Additionally, the authors propose barring “lifestyle advertising” around vapes, restricting communications to “a ‘switch’ message in accordance with the continuum of risk.” They also want to require state and local governments to “establish strict licensing policies and practices that limit youth access to all tobacco and nicotine products,” and demand clear communication on “the relative risks across the nicotine continuum of risk”—including both accurate information to adults about the potential benefits of switching and warnings to youth “that no nicotine-containing product is fully safe to use” and “all can be addictive.”
While the paper contains a raft of recommendations that will be hotly disputed, some of its conclusions, at least, will probably draw relative agreement from harm reductionists.
“The public’s ignorance about both nicotine’s and e-cigarettes’ substantially lower risk than that associated with smoking makes it likely that fewer people who smoke will attempt quitting smoking with e-cigarettes than would occur were the public (especially smokers) more knowledgeable about the health risks of e-cigarettes and nicotine per se,” the co-authors contend. “In turn, because quitting smoking significantly reduces the risk for disease and death, smoking’s toll is likely higher than it would be in an environment more receptive to the use of e-cigarettes to quit smoking. Inadvertently, the nation’s overwhelming focus on e-cigarettes’ risks for adolescents may be harming the public’s health.”