SOUTHFIELD - It’s never a good time to enforce policy during a time of panic. But that’s what some public health officials say Michigan did when it announced a ban on sales of flavored e-cigarette products.
“You’ll regret it later,” said David Abrams, a professor of global public health at New York University.
When Michigan announced its outright ban, it was against a backdrop of health-related reports of hundreds of people contracting lung-related illnesses and dying from complications tied to vaping. While the decision was made with the right intention, Abrams is among a collection of public health officials who believe blanket bans on flavored e-cigarette products could do more harm than good.
Both he and Dr. Kenneth Warner, the former dean of the University of Michigan’s School of Public Health who specializes in health policy related to tobacco use, say most kids who currently vape already smoked cigarettes. Any ban on flavored options would push them, and adults who vape, back to smoking products with tobacco.
“Kids vaping a lot are primarily either current cigarette smokers or former smokers. It’s far less hazardous than smoking (tobacco) and if they switched to vaping, that’s a net improvement,” Warner said. “The big concern is by banning all flavors, given adults like flavors too, you may be discouraging them from trying to quit smoking, or encouraging those who have quit to go back to it.”
Warner and Abrams say that because most students who now vape were already using other tobacco-related products, a statewide ban like what Michigan, New York and more recently Massachusetts and Rhode Island have placed could push those same kids back to cigarette smoking - which studies show is unhealthier than vaping.
However, following large increases among youth vaping, the Department of Health and Human Services announced a public health emergency.
“We’ve just seen sky-rocketing numbers among kids in middle and high school in recent years and what we’ve found was the flavored nicotine e-cigarettes are particularly appealing because of the flavor,” said Bob Wheaton, a spokesman with the MDHHS. “These flavors are designed to attract children to get them to start.”
In a study that’s currently under review, Abrams looked at data pulled from a report in the 2018 National Youth Tobacco Survey. Researchers found among high school students who frequently vaped, 88.1 percent of them previously or still use tobacco. Among students who infrequently vaped, 60 percent previously or still use tobacco.
However, Wheaton argued that studies like these depend on assumptions and often the models they rely on have limitations.
“Much of the current evidence of e-cigarette use and the impact on smoking initiation and smoking cessation is unable to conclude a cause and effect,” Wheaton wrote in a follow-up email. “Our key point is that what MDHHS and Gov. Whitmer want to do is protect children’s health. Vaping by teens is skyrocketing, and that is negatively impacting children’s health.”
However, a blanket ban on all flavored e-cigarette products makes it harder for adults to quit smoking tobacco, contends Warner. The professor, who said he’s a former smoker and doesn’t vape, said policies like these and ad campaigns that personify vaping as being as bad as smoking tobacco are irresponsible and sets back years of progress in helping people quit smoking.
“Adults now believe vaping is as dangerous as cigarettes. They aren't even close,” he said. “I do think it's shortsighted. Worst than that, it could cause a number of smoking-related fatalities among adults who would give up vaping and go back to cigarettes.”
Wheaton said that’s why officials at the health department opted to ban only flavored products.
“We did want that alternative for adults who were quitting smoking. Obviously we do want people to quit smoking. We don’t want to ban all e-cigarettes,” he said. “But it was the flavored smoking that was most attractive to children who had not previously smoked.”
However, Warner said many adults who quit smoking like the flavors. Instead, the states should adopt laws where products with nicotine in them can’t be sold to anyone under the age of 21 and should prohibit the sale of flavors in venues that kids can walk into. E-cigarette flavors are sold at convenience stores, vape shops, grocery stores and gas stations.
Michigan was the first state to ban flavored e-cigarettes, making the announcement on Sept. 4. The federal government and New York state soon followed. The state’s six-month ban on the sale of flavored nicotine vaping products went into effect Sept. 18.
Their recommendations come amid reports from the FDA, CDC as well as several state health departments worried about the spike in e-cigarette usage among teens. The FDA reports a 78 percent increase from 2017 to 2018 among high school students now vaping.
“The increase in nicotine vaping from 2017 to 2018 was the largest increase in the 44 continuous years of our project, for any substance,” Richard Miech, a principal investigator at Monitoring the Future, which collects data on drug use, wrote in an email. “In 2019, the increase continued unabated, with the increase ranking in the top 5 for both 12th and 10th grade.”
That worrying trend is further magnified by the 805 cases of respiratory illness that has hospitalized people who use e-cigarettes or vaping products. Nearly three-quarters of those cases were males and two-thirds of the cases were people between the ages of 18 and 34. As of Sept. 26, 12 people have also died from using the products. But Abrams said every death was related to adulterated marijuana oil and not conventional nicotine e-cigarette products.
“This is a sudden outbreak in a few areas after 10 years of millions of people using nicotine they purchased in stores made by commercial manufacturers. There wasn’t a single case like this in 10 years,” he said. “You got to ask why you’re suddenly seeing this pop-up of massive illness and eight deaths in a two month period?”
So what’s going on? Abrams, who doesn’t smoke tobacco but occasionally vapes, thinks a bootlegged nicotine or marijuana product made its way to the market and is making people sick. On Sept. 18, two brothers from Wisconsin were arrested in connection with a “massive counterfeit THC vape cartridge operation (https://www.rollingstone.com/culture/culture-news/wisconsin-brothers-thc-vape-cartridge-operation-886581/)” that churned out “thousands of THC-filled cartridges per day.”
On Sept. 20, theWall Street Journal reported (https://www.wsj.com/articles/sales-of-illicit-vaping-products-find-home-online-11568971802) how illicit cannabis-vaping products were thriving online. While technology companies like Facebook and Amazon have policies against illegal and inappropriate sales, and the CDC issuing warnings against purchasing unregulated THC and vaping products, the digital marketplace for these potentially adulterated consumables has boomed.
Abrams thinks a blanket ban on flavored e-cigarette products would further spur this black market - just look at states that have bans on marijuana.
“One could argue, and this is the case that most states that ban marijuana, people are buying legal marijuana from states and selling it on the black market,” he said. “The black market is causing the deaths and the harm.”
Warner said students are going to experiment with drugs, whether the product is legal or not. Instead of limiting the options that aren’t as harmful as tobacco, we should be building on the momentum of declining smoking rates among teens and people in general.
“We should be celebrating what has happened with smoking in kids. High school seniors and the national youth tobacco uses are down to 5.8 percent. Go back to the mid-1990s, the numbers were more than a third,” Warner said. “What is interesting, declines (in tobacco usage) has accelerated during times when kids have been vaping.”
In a study (https://tobaccocontrol.bmj.com/content/early/2018/10/31/tobaccocontrol-2018-054446) published in 2018, researchers looked at the relationship between rates of teens that vape, and rates of teens that smoke tobacco. During a “substantial increase” in youth vaping in 2014, the rate of teen smoking declined much faster during that period. While researchers said the relationship was “robust,” they stopped short of stating that vaping caused this decline, and encouraged more research in the field.
Miech said “it would be quite difficult” to separate which teens quit smoking because of vaping and which were going to stop regardless.
“This is particularly difficult to tease out because teen cigarette smoking has been steadily declining since the year 2000, long before vaping existed,” he wrote.
Miech cited drug use among youth as “socially constructed” and that use among almost every harmful substance had fallen, except for vaping. “The decline of teen smoking and teen drug (use) since 1998 shows that we can bring down teen drug use through processes other than addicting them to nicotine through vaping.”
A lot of groups have come out in support of the ban, stating that until we have a better understanding of the health effects of vaping, it should be kept as far away from young kids as possible.
“Both states and the federal government are going to have to look at that,” said Meghan Swain, the executive director of the Michigan Association for Local Public Health. “How did we lose our way and get this far into another problem with tobacco and nicotine? I’m...hopeful that states and the federal government continue to focus on that.”
Andria Eisman, a research assistant with the Department of Health Behavior and Education said new policy presents an opportunity to promote prevention and making sure people have access to effective prevention.
“In schools, we can help push forward the idea of prevention to get to young people before they get addicted," she said. "It’s going to take a multi-tiered approach.“
However, Abrams worries Michigan’s ban could set back the progress the country has made in ending tobacco use.
“We literally have the opportunity to kill cigarettes forever. And that may mean leaving a less-harmful form of nicotine on the market.”
Jack Nissen is a digital reporter at Fox 2 and can be reached at firstname.lastname@example.org