Something very curious is happening as anti-tobacco groups led by the Campaign for Tobacco Free Kids seek city-by-city, state-by-state bans on flavored tobacco products.
They have succeeded in just one state — Massachusetts, which ended the sale of all flavored tobacco products, including menthol cigarettes, e-cigarettes and cigars, last June. In a full-page ad in The Boston Globe, the anti-tobacco groups thanked lawmakers “for protecting our kids and communities.”
And yet. Sales tax data shows that as cigarette sales declined in Massachusetts, they grew in neighboring states — an early indication that the bans may not be reducing tobacco consumption.
Elsewhere, what began as campaigns against all flavored tobacco products — the menthol cigarettes that kill smokers, the flavored cigars that are popular with young Black people and the flavored electronic cigarettes that have provoked alarm among middle-class parents — evolved into something entirely different.
New York, New Jersey, Rhode Island and the cities of Chicago and San Francisco passed laws that banned flavored e-cigarettes and left combustible tobacco untouched.
This is exactly wrong, many public health experts say. NY, NJ, RI, Chicago and San Francisco left the most dangerous tobacco products — combustible cigarettes — on the market and removed a safer alternative.
“It makes no sense to ban e-cigarettes, but permit the sale of tobacco and cannabis,” says Steve Schroeder, a physician, professor of medicine at the University of California at San Francisco and the former president of the Robert Wood Johnson Foundation.
Menthol cigarettes kill. They “were responsible for 10.1 million extra smokers, 3 million life years lost and 378,000 premature deaths” between 2000 and 2018, according to a recent study in Tobacco Control by Thuy Le and David Mendez of the University of Michigan.
“The case is quite clear in favor of banning combustible mentholated cigarettes,” Mendez tells me. [See my story in Medium about calls for a national menthol ban.]
E-cigarettes do not kill users, at least as far as we know. They are safer than cigarettes, nearly all scientists agree, even though they contain nicotine, which is addictive and may affect the development of adolescent brains.
Needless to say, young people who are not smokers should stay away from e-cigarettes. Their long-term health effects are unknown. But smokers who can switch to vaping should do so. Many thousands have, especially in the UK, where the government recommends using e-cigarettes to quit smoking.
“Across a range of studies and outcomes, e-cigarettes appear to pose less risk to an individual than combustible tobacco cigarettes,” said the US National Academies of Sciences, Engineering, and Medicine in 2018, after conducting a thorough review of the evidence.
A gateway or an off-ramp?
E-cigarettes also do not seem to be a gateway to smoking, despite claims from anti-tobacco groups. The nonprofit, anti-tobacco Truth Initiative declares that “young people who vape are much more likely to become smokers,” but trends in teenage tobacco use say otherwise.
If anything, it seems probable that the adoption of e-cigarettes has helped drive down teen smoking rates. This is from the introduction to a forthcoming paper by Michael Pesko of Georgia State University and Casey Warman of Dalhousie University and the National Bureau of Economic Research:
In 2009, public health officials in the United States established Healthy People 2020 goals that among other things called for reducing youth cigarette use from 19.5% to 16.5% by 2019. By 2019, the youth cigarette use rate was at a remarkable 6.0%, thus beating Healthy People 2020’s ambitious goal of a 3 percentage point reduction (from 19.5% to 16.5%) over the decade by 350%. What caused the decline in youth cigarette use to be so under-estimated? One candidate is the introduction of e-cigarettes.
Mendez, the Michigan tobacco expert, says: “What’s happening lately with youth smoking is extraordinary.”
Vaping played a role but so, it seems likely, have the persistent efforts of the Campaign for Tobacco-Free Kids and The Truth Initiative.
Instead of declaring near-victory over teen smoking, however, Tobacco-Free Kids and its allies have doubled down on their efforts to ban flavored e-cigarettes. The question is, why?
It’s true that e-cigarette use by teenagers grew rapidly during the mid- to late-2010s. But all the talk about an “epidemic” and the “skyrocketing youth use” of e-cigs seems designed to whip people into a moral panic. The Centers for Disease Control reports that about 7.5 percent of high school students frequently used e-cigarettes in 2020. That’s down from 9.4 percent in 2019. Daily use is slightly lower.
Some of the focus on e-cigarettes is surely driven by money: Bloomberg Philanthropies is funding a three-year, $160m campaign against flavored e-cigarettes led by Tobacco-Free Kids. [See my deep dive in the Chronicle of Philanthropy about Bloomberg Philanthropies, Tobacco-Free Kids and e-cigarettes.] Middle-class and upper-class parents — potential donors to the anti-tobacco groups — fear vaping more than smoking, which has all but disappeared among the college educated and well-to-do.
It could also be that the anti-tobacco activists understandably harbor deep distrust, if not hatred, for the big tobacco companies, which have repeatedly misled consumers about “safer cigarettes.” The Altria Group, which is the parent company of Philip Morris USA, which owns Marlboro, and Reynolds American, a unit of British American Tobacco, which owns Camel and Newport, have invested heavily in vaping brands.
Michael Siegel, a physician, professor of public health and anti-tobacco activist at Boston University, says: “The zealotry against cigarettes and smoking is so strong that the tobacco control movement cannot accept the idea that a behavior that looks anything like smoking can possibly deliver a public health benefit.”
To be sure, ultimate responsibility for the bans on flavored vapes belongs to lawmakers. (The San Francisco ban was enacted by voters and financially backed by Michael Bloomberg.) The anti-tobacco forces favored sweeping bans that would have included combustible tobacco.
By email, Sweanor tells me:
The totality of decades of research on tobacco and disease can be summed up in just four words: ‘it’s the smoke, stupid’. To remove low-risk non-combustible products from the market while lethal cigarettes remain readily available protects the cigarette business rather than public health. It is counter to a very long and successful history of facilitating moves to ever less hazardous goods, services and behaviors.
The most outrageous aspect of these measures is that the cigarette market, responsible for nearly half a million US deaths annually, is being protected by people who claim to be anti-smoking advocates.
Tobacco-Free Kids declined to respond to Sweanor, but told me by email that “every major U.S. public health authority — including the U.S. Surgeon General, the FDA and the U.S. Preventive Services Task Force — has found there is inadequate evidence to conclude that e-cigarettes are effective for smoking cessation.” The U.S. Preventive Services Task Force, for example, said in January that “the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined.”
To be sure, there’s much still to be learned about e-cigarettes. Public health and tobacco experts are deeply polarized about how to regulate vaping.
But that’s reason for Bloomberg Philanthropies and Tobacco-Free Kids to proceed carefully and to engage openly with their critics — something they have been reluctant to do. The debate is ongoing; Bills taxing or regulating e-cigarettes were introduced in 18 states last year, and legislation is moving forward in Connecticut and Vermont, among other states.
One last thought: Nothing in this story is intended to diminish the suffering of parents whose kids get addicted to e-cigarettes. In a new podcast from Parents Against Vaping, a mother from Connecticut describe the ordeal of her teenage son who, she says, became addicted to vaping and suffered from depression, anxiety and shame, threatened suicide and could not kick his nicotine habit even after eight weeks in a wilderness camp.
In response, states and cities could step up enforcement of Tobacco 21, the US law requiring all buyers of tobacco products to be at least 21 years of age. Rogue retailers could be held accountable. The goal would be to keep all tobacco products out of the hands of young people, without keeping flavored e-cigarettes away from smokers who want to quit. About 34 million adults in the US currently smoke cigarettes, and more than 16 million live with a smoking-related disease. They are too often forgotten in this debate.