President Donald Trump signed legislation in December 2019 to amend the Federal Food, Drug and Cosmetic Act by raising the federal minimum age of sale for tobacco products from 18 to 21. “Tobacco products,” in this case, includes both smoked and smokeless tobacco, but also nicotine vaping products.
Protecting young people’s health was the rationale. But will raising the age of sale actually reduce harms for 18 to 20-year-olds?
First we must question the inclusion of vaping products in this legislation, when the best available evidence indicates that vaping is 95 percent less harmful than smoking. (Smokeless forms of tobacco such as snus also pose significantly lower harms than smoking, but we’ll focus on vaping because of its much greater uptake among young people.)
Proponents of the legislation note that vaping is not completely risk-free, which is true. They also say that the use of e-cigarettes will drive young people to smoking, which is not supported by the evidence.
What might many young people who vape do instead when the option of vaping legally is taken away?
In the US and UK, there have been similar long-term gradual declines in smoking rates in young people. If increased vaping rates were really causing young people to smoke more cigarettes at the population level, surely these reductions in youth cigarette smoking would be slowed or reversed?
This, however, is not happening, which suggests that e-cigarettes are not undermining decades of efforts to prevent youth smoking. In fact, bans on e-cigarette sales to minors have been shown to slow the consistent drop in youth cigarette smoking by about 70 percent. “In other words, as a result of these [e-cigarette] bans, more teenagers are using conventional cigarettes than otherwise would have done so,” said Abigail Friedman, assistant professor of public health at Yale University.
This finding makes perfect sense. Although young people are using more e-cigarettes, as has been heavily publicized, the prevalence of cigarette smoking among high school students has dropped to all-time lows. Meanwhile, according to the US Department of Health and Services, nearly 90 percent of adult smokers began smoking before the age of 18.
In light of these two facts, what might many young people who vape do instead when the option of vaping legally is taken away?
Experience with many substances tells us that making them illegal doesn’t mean that people stop doing them. While some young people might become abstinent, others will just seek nicotine illicitly. And illicit-market vapes or cigarettes are far riskier options than regulated vaping devices.
From a public health standpoint, it is therefore unethical to suddenly take these products away from people under 21, just as it is to place e-cigarettes and combustibles in the same category.
I once worked in a detox facility in Miami; most people under 21 in the recovery community there weren’t smoking cigarettes but were vaping instead. These people, who were looking to move beyond their problematic relationships with other drugs, were using e-cigarettes as a harm reduction tool to get through drug treatment. In some jurisdictions, rehab bans on smoking and vaping, even outdoors, have had disastrous consequences, as Filter has reported.
Beyond a public health framing, there’s also the question of personal autonomy for people who are legally adults. Surely the age of consent for all things should be the same? If you’re old enough to fight in a war, to consent to major surgeries, to vote or get married, then you should certainly be old enough to drink, smoke or vape.
I’ve witnessed countless people from the ages of 15 to 20 use fake IDs to buy alcohol and cigarettes. According to the 2018 National Survey on Drug Use and Health, about 9 million people aged 12-20 used tobacco products and 15 million used alcohol. This undermines the idea that banning cigarettes for under-21s will prevent all access (a point which fortunately also applies to vapes).
Underage drinking, despite the law, is part of American culture in colleges and many other contexts. But people under 21 frequently make poor decisions in how they consume alcohol, given a lack of education on safer consumption because they’re simply not supposed to be doing it. This consequence of an abstinence-only policy could equally apply to to different forms of nicotine consumption with wildly different risk profiles.
Anti-Vaping Propaganda
My first experience with anti-vaping propaganda was in 2017, when I was working as a drug and bullying prevention counselor for elementary and high school students. One of the trainings I attended focused on the harms of vaping. The training asserted that e-cigarettes are more harmful than cigarettes.
I was shocked to hear such a misinformed, negative view on a potentially lifesaving tool from public health professionals and other folks with “PhD” next to their name.
In support of this contention it cited studies of factory workers, exposed to high levels of diacetyl while producing food flavorings, who contracted Bronchiolitis obliterans syndrome, popularly known as “popcorn lung.”
While some e-liquids contain small quantities of diacetyl, the idea that vaping causes popcorn lung is a persistent myth. Exposure to diacetyl from vapes that do contain it is 750 times lower than from smoking.
I was shocked to hear such a misinformed, negative view on a potentially lifesaving tool from public health professionals and other folks with “PhD” next to their name. When I queried this, the presenter stated that they weren’t sure, leading me to believe that they likely did not read the study cited or deepen their understanding beyond “diacetyl is bad.”
Years later, in another training about vaping that I attended as a medical case manager, an MD spoke about the harms of vaping and specifically said that vaping will cause popcorn lung. When I asked him what he thought about the levels of diacetyl present in e-cigarettes versus cigarettes, he similarly stated that he didn’t know.
One particular “popcorn lung” study has been misconstrued time and time again, with anti-vaping proponents using it to say that e-cigarette use will cause fatal lung disease due to diacetyl. A web search for “vaping popcorn lung” will lead you to countless websites, such as the American Lung Association’s Lung.org, wrongly stating that e-cigarettes will cause irreversible lung damage. Proper interpretation of the original study would lead to the conclusion that just like other substances, including water and aspirin, the dose makes the poison and only extremely high levels of these substances would cause harm.
As a person who has vaped and made their own e-liquids, I can add that an e-liquid containing enough diacetyl to cause the harms referenced would likely taste horrendous.
Other potentially harmful chemicals found in cigarettes, such as formaldehyde, acetaldehyde, and acrolein are also found in e-liquids, but in tiny quantities. E-cigarettes emit about 99 percent less of these chemicals than combustible cigarettes. Again, this is not about claiming that vaping has zero harms, but assessing relative risks in harm reduction terms.
During both of the trainings I mentioned, another familiar line of attack was used: the idea that vaping flavors are specifically appealing to youth. This widely accepted charge was instrumental in obtaining the partial ban on vaping flavors that was announced by the federal government this month.
But of course, the attraction of vaping flavors enhances the efficacy of this harm reduction tool in leading both adults and teens away from cigarettes. It’s one factor that contributes to vaping being about twice as effective a quit-smoking aid as nicotine patches or gum.
Filter has extensively covered the culpability of the CDC and other US public health agencies in contributing to a drug panic around the outbreak of “vaping-related” lung injuries in 2019. Vitamin E acetate in illicit THC products was found to be overwhelmingly responsible for these injuries and deaths. It was lack of access to legal THC products that exposed consumers to the inherent risks of an unregulated market.
Similarly, removing people under 21 from the legal vape market will inevitably drive many to unregulated sources, or to the cigarettes that have killed millions.
Young adults who choose to use substances, including nicotine, deserve harm reduction like everyone else.
Vaping products represent a breakthrough in the way people consume nicotine, with the unprecedented potential to make cigarettes obsolete. Attacking these products for the possibility of enticing youth users is the last thing we should be doing.
Yet while public health bodies and medical professionals in the UK and other countries suggest switching from smoking to vaping, the US continues to spread misinformation, fueled by anti-vaping lobbyists such as the Campaign for Tobacco-Free Kids, the Foundation for a Tobacco-Free World and the American Nonsmokers’ Rights Foundation.
The new national age restriction is part of what Drug Policy Alliance founder Ethan Nadelmann recently called “the great new drug war of the 21st century.” We need to end this war—not only because it doesn’t work, but to pave the way for policies and interventions that can reduce harms.
More focus needs to be put on reality-based drug education programs for young people, such as Students for Sensible Drug Policy’s Peer Education Program or DPA’s Safety First curriculum. We can all be involved by confronting misinformation and junk science and educating our peers. Numerous groups like the Consumer Advocates for Smoke-Free Alternatives Association, the American Vaping Association, and the Vapor Technology Association are also doing this work.
The total failure of prohibition and the War on Drugs must in all cases be replaced by accurate information, pragmatism and compassion. Young adults who choose to use substances, including nicotine, deserve harm reduction like everyone else.
Image via Joint Base San Antonio/Public domain
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