In the summer of 2018, San Francisco residents voted overwhelmingly to ban the sale of flavored nicotine vaping products (as well as flavored tobacco products, including menthol cigarettes). By January 2019, when the prohibition took effect, almost every retailer in the city was immediately compliant. It had been an expensive fight, with companies that sell vaping products spending tens of millions of dollars on one side and billionaire Michael Bloomberg, a longtime anti-smoking funder who has since turned his abstinence-only approach to vaping, bankrolling the opposition with millions of his own.
At the time, prominent public health organizations, like the American Cancer Society, and other influential nonprofit groups, such as the Bloomberg-funded Campaign for Tobacco-Free Kids (CTFK), lauded the result. Dr. Melissa Welch, a spokesperson for the American Heart Association, which urged voters to approve the ban, told The New York Times that “she hoped the San Francisco vote would be a first step toward ending ‘the sale of candy-flavored tobacco before nicotine claims a new generation of young people.”
The flavor ban, though, does not seem to have achieved that wish. In fact, it may have led to an even more troubling situation.
“Among youths who vape, some likely prefer ENDS to combustible products because of the flavors.”
A new study published in JAMA Pediatrics found that after San Francisco’s ban on flavored vapes and tobacco products, teenagers in the city’s high schools were more likely to take up smoking than teenagers in other US school districts. (San Francisco later became the first US city to ban sale of all e-cigarettes, but the effects of that were not the subject of the study.)
Prior to the flavor ban, smoking rates in San Francisco paralleled many cities across the country, showing fewer teens using combustible cigarettes over time. After the city enacted its policy, the odds of smoking among its high school students, relative to trends in comparison school districts, more than doubled.
“To understand this conceptually, think about youth preferences between tobacco products,” Abigail Friedman, the author of the study and an assistant professor in the Department of Health Policy and Management at the Yale School of Public Health, said in a statement. “Among youths who vape, some likely prefer ENDS to combustible products because of the flavors.”
“For these individuals as well as would-be vapers with similar preferences, banning flavors may remove their primary motivation for choosing vaping over smoking,” she continued. “Thus, some of them will respond to a ban on flavors by choosing to use combustible products instead of ENDS.”
Dr. Friedman used biennial high school student data from the 2011-2019 Youth Risk Behavior Surveillance System’s school district surveys conducted by the Centers for Disease Control and Prevention (CDC). Among other categories, these surveys monitor alcohol and drug use, tobacco use and sexual behaviors “related to unintended pregnancy and sexually transmitted diseases.”
Friedman ran statistical regressions comparing recent smoking from respondents in San Francisco versus other school districts, both before and after San Francisco implemented its flavor ban. None of the other school districts that Friedman considered in her analysis—including New York City; Broward County, Florida; Los Angeles; Orange County, Florida; Palm Beach County, Florida; Philadelphia; and San Diego—had a flavor ban in effect during that time frame.
“The public needs to recognize just how lethal smoking is,” Friedman told Filter. “In the US alone, combustible tobacco use is responsible for about 480,000 deaths annually. That’s more deaths than the CDC’s count for US COVID-19 deaths in 2020, but happening every year. So being safer than smoking is not a high bar.”
“The safest option is not using any tobacco products,” she continued. “However, if you are going to use tobacco, avoiding the most lethal mode of delivery is common sense, and smoking is likely to be far worse for your health than vaping a nicotine e-liquid from a well-established brand.”
The UK’s Royal College of Physicians has estimated that the harms of e-cigarettes are “unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”
Friedman’s paper, which she shared at the US E-Cigarette Summit, arrives at a moment when the discourse around vaping in the States appears to be—slowly—shifting. Two high-ranking members of the Food and Drug Administration (FDA), who presented alongside Friedman, directly spoke about the inevitability of (at least some) vaping products receiving their agency’s approval. (By September, the FDA is supposed to rule on millions of premarket tobacco product applications; while a decision on all of them remains unlikely, the agency has signaled that it will decide on the largest manufacturers first.)
The FDA’s willingness to say that it’ll soon regulate the vaping market has profound implications. The agency will, in effect, finally be endorsing that vaping nicotine carries much less risk than smoking. And, in many ways, it will also be providing a long-overdue corrective to the poor legislative decisions that reacted to the soaring youth vaping rates of the late 2010s. More and more evidence emerges that knee-jerk prohibitionist strategies had a major unintended consequence that increased, rather than reduced, harms. They appear to have led to more smoking.
“When we shift policies really dramatically—from looser regulations to much stricter ones—there’s no space for the folks who had access before.”
Such strategies gave no consideration to the nicotine marketplace that already existed before, nor to the fact that millions of adult smokers have successfully used vapes and flavors to transition from cigarettes to lower-risk alternatives.
“On the one hand, these [flavor bans] are meant to supposedly prevent exposure,” Dr. Sheila Vakharia, the deputy director of the Department of Research and Academic Engagement for the Drug Policy Alliance (DPA), told Filter. “It’s this idea that exposure alone is going to lead to widespread use, dependency, and problems. There’s this belief that we need these sorts of policies to protect people from themselves. The problem, though, is that when we shift policies really dramatically—from looser regulations to much stricter ones—there’s no space for the folks who had access before.”
We are watching the illumination of the consequences in real time. Friedman’s study is only the latest example. Earlier in May, a study in the Harm Reduction Journal published new information linking misinformation about vaping and the series of lung-related illnesses from the summer of 2019 with an uptick in cigarette smoking. (The CDC eventually tied the “e-cigarette or vaping product use-associated lung injuries,” or “EVALI,” to an adulterant in some illicit THC cartridges.) And that same month, another study—published in Nicotine & Tobacco Research—suggested that teens who vape would probably be smoking cigarettes instead if vapes had never become available.
An uncomfortable truth lingers here, one that many stakeholders wouldn’t dare to utter. No sensible person is encouraging teens who don’t use nicotine to try vaping. But for teens who would otherwise be smoking, it’s a huge win.
The outcome in San Francisco is the opposite.
Photograph by Mike Mozart via Flickr/Creative Commons 2.0
The Influence Foundation, which operates Filter, previously received a restricted grant from DPA to support a Drug War Journalism Diversity Fellowship. Dr. Vakharia is a member of the board of directors of The Influence Foundation.
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