States that have banned the use of electronic cigarettes and vaporizers by those under age 18 — including North Carolina — have experienced an increase in youth traditional cigarette smoking, according to a Yale University study.
The paper by researcher Abigail Friedman, published Oct. 19 in the Journal of Health Economics, appears to counter a prevailing anti-tobacco advocacy message: that e-cigs and vaporizers can and are serving as a youth gateway to traditional cigarettes.
The typical e-cigarette is a battery-powered device that heats a liquid nicotine solution in a disposable cartridge and creates a vapor that is inhaled. They also are known as ciga-likes.
By comparison, a vaporizer can be supplied and reused through the insertion of a liquid capsule.
North Carolina’s youth e-cig ban went into effect Aug. 1, 2013. A law was amended to add e-cigs and vapor products to the list of tobacco products that cannot be sold or distributed to people under 18. Reynolds American Inc. supported amending the law.
“The empirical findings provide the first causal evidence that e-cigarette access reduces teen smoking,” Friedman wrote.
“Regression analyses consider how state bans on e-cigarette sales to minors influence smoking rates among 12- to-17-year-olds. Such bans yield a statistically significant 0.9 percentage point increase in recent smoking in this age group, relative to states without such bans.
“This effect is consistent with e-cigarette access reducing smoking among minors. Banning e-cigarette sales to minors counteracts 70 percent of the downward pre-trend in teen cigarette smoking in the states that implemented such bans.”
Friedman said her findings “will prove surprising for many. Policy discussions to date have not considered that banning e-cigarette sales to minors might increase teen smoking.”
“Assuming that e-cigarettes are indeed less risky to one’s health than traditional cigarettes, as suggested by existing evidence on the subject, this result calls such bans into question.”
Friedman recommends as a potential “middle ground” banning e-cigs and vaporizers for those under age 16, “as initiation of regular smoking first spikes at (that) age.”
States impose bans
For the study period of 2009-13, 24 states had banned the sale of e-cigs and vaporizers to those under 18. An additional 16 states have passed a ban since Jan. 1, 2014.
The Food and Drug Administration recommends a federal ban. Friedman wrote that “a FDA decision not to ban e-cigarette sales to minors, after having announced this intention, could be seen as sanctioning teen vaping, introducing distinct costs not addressed here.”
Friedman said her research examined “the causal impact of e-cigarette access on conventional cigarette use by adolescents,” such as determining whether e-cigs and vaporizers are reducing the stigma, or renormalizing, smoking, as some anti-tobacco advocates claim.
“Understanding electronic cigarettes’ effect on tobacco smoking is a central economic and policy issue,” Friedman said.
In April, the FDA and Centers for Disease Control and Prevention reported that traditional cigarette smoking rates among high schoolers were found to have dropped to an all-time low of 9 percent in 2014, compared with 13 percent in 2013.
Meanwhile, electronic and vapor cigarettes moved to the top of seven product options at 13 percent, up from 4.5 percent in 2013.
Anti-tobacco advocates stressed the increased use of e-cigs among youths, to the point of overshadowing the progress made on traditional cigarette usage.
The latest phase of potential FDA tobacco regulations focuses on product innovations. A federal health report released in August expressed concern that flavorings in tobacco are enticing use by youth, particularly with vaporizers.
On Oct. 20, the Federal Trade Commission said it wants permission from the Office of Management and Budget to collect flavoring and nicotine level information from five large and 10 smaller e-cig and vaporizer marketers.
Meanwhile, anti-smoking advocates tout that the products can help wean adults from traditional cigarettes and potentially represent a less harmful way to consume nicotine.
Appeal may fade
Friedman said it is possible that as the novelty around e-cigs and vaporizers abates, youths may lessen their use of those products. Other potential influences include overall federal regulations of the products, particularly flavorings, and whether large tobacco manufacturers eventually dominate the marketplace, as projected by analysts, anti-smoking and anti-tobacco groups.
“The potential long-run health effects from e-cigarettes themselves, as well as complementaries with other risky behaviors, such as alcohol consumption, are not addressed” in the study, Friedman wrote.
“As data on such consequences becomes available, they will clarify the product’s full costs and benefits” to society.
Brad Rodu, a professor of medicine at the University of Louisville and a smokeless-tobacco advocate, said he finds Friedman’s under-16 ban proposal “sensible and defensible.”
“Currently, e-cig companies and advocates support bans on e-cig sales to minors,” Rodu said.
“Health organizations, like the American Cancer Society and American Heart Association, object to youth e-cig use, but they oppose bans because companies support them. The health groups believe that youth bans are not as effective as higher sales taxes and smoke-free or clean-air laws.”
Dr. Gilbert Ross, medical and executive director of the pro-business American Council on Science and Health, expressed concern that though the adult and youth smoking rates have decreased substantially nationwide, "that trend has significantly lessened among those states with youth e-cig bans."
Dr. John Spangler, a family and community medicine professor at Wake Forest Baptist Medical Center, said he believes Friedman’s research has flaws.
“This study does not account for unmeasured factors, such as racial and ethnic population mix in states, even though we know race and ethnicity have dramatic effects of cigarette smoking,” Spangler said.
“Using population data only, one cannot measure the combined effects of risk-taking behaviors by individual teens. It could be that teens in states with bans are more likely to buy e-cigarettes simply for the thrill, and we already know that risk-taking teens smoke at higher rates.
“Although these are interesting findings, they raise questions that can only be addressed by a different study design, such as a cohort study,” Spangler said. “Such large cohort studies are on-going.”
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