Efforts to curb young adult vaping by banning flavored products are successful, but new research shows those legislative bans are also leading to a rise in smoking traditional cigarettes.
The study from researchers at the University of Missouri and the Yale School of Public Health also found that a more nuanced approach in Maryland.
The findings illuminate the central debate in the public health community: Prohibition vs. harm reduction. Pragmatists say prohibition isn’t a realistic option, and smokers should be encouraged to switch from traditional tobacco cigarettes to alternatives like e-cigarettes, pouches and vaping.
Anti-tobacco proponents argue that because the alternatives may also hold some health risks — though far lower than traditional cigarettes — the public health policy should be to try to end all nicotine use entirely.
Study co-author Michael Pesko, the J. Rhoads Foster Chair of Economics at the University of Missouri, said their findings show the downside of the prohibition approach.
The research, published in JAMA Health Forum, looked at 242,154 young adults age 19 to 29 and found those living in states with restrictions on electronic nicotine devices reduced their daily vaping and tobacco cigarette smoking rates. While the data analysis found an 80 percent reduction in daily vaping, it also found a 22 percent increase in daily smoking compared to 2018 rates.
“It makes sense to make more lethal products as undesirable as possible and provide incentives for people that demand nicotine to use less dangerous products instead by, for example, allowing greater flavor availability,” Pesko said.
According to the American Lung Association, 14 percent of adults smoke traditional tobacco cigarettes, a far lower number than two generations ago. From 1965 to 2022, the rate of smoking among adults fell 73 percent. For young adults, rates fell 57 percent from 2017 to 2022.
The JAMA study found that rates of young adults using electronic nicotine delivery systems — vaping, e-cigarettes, pouches, etc. — rose from 5.4 percent in 2014 to 13.6 percent in 2022. Meanwhile, the rate of smoking traditional tobacco cigarettes went from 17.9 percent to 6.5 percent over that period.
In nearly every state and local jurisdiction that has prohibited flavored e-cigarettes, the study found that traditional cigarette use rose.
“We should always be cognizant that any policy will have unintended effects, especially in the public health space,” Pesko told MedicalExpress. “This is not good from a public health perspective because cigarettes are far more dangerous products. It’s the equivalence of steering a ship away from a storm straight into a whirlpool.”
Maryland, on the other hand, presents an alternative scenario.
Maryland has banned the sale of flavored electronic smoking devices, but it exempted menthol from the ban. The result was a decline in vaping and smoking rates.
In the 2019-2019 school year, 235 Maryland high school students used e-cigarettes, which, at the time, was the highest recorded percentage of electronic device use in the state, according to the Maryland Department of Health. By the 2022-2023 school year, a department spokesman said usage rates had dropped to 14.3 percent.
“While the use of these tobacco products is decreasing, Maryland high school students are still using e-cigarettes nearly five times more than cigarettes,” Health Department spokesman Chase Cook said in an email to InsideSources.
In contrast to youths, Maryland adults smoked traditional cigarettes at a higher rate than those using electronic devices. The Health Department said that in 2023, 9.1 percent of adults used combustible cigarettes, while 5.1 percent used electronic devices.
In the study, the researchers found that Maryland’s restrictions on nonmenthol flavors translated to reductions in the use of combustible and electronic cigarettes. They also noted that there is growing evidence that policies making electronic nicotine delivery systems (ENDS) more expensive or less appealing can lead to an increase in traditional cigarettes.
“Although our findings will disappoint advocates of aggressive ENDS flavor restrictions, the findings regarding Maryland’s policy suggest an alternative,” the authors wrote. “Because that policy exempts the open-system ENDS used more by adults than youth, it may offer a better target for interventions to reduce youth use without impeding adult smokers’ substitution away from combustible cigarettes.
“Or perhaps exempting menthol ENDS dampened cross-product substitution so that those who vaped flavors and did not want to quit were nudged toward vaping menthol instead of smoking cigarettes,” they wrote.
Pesko says improving public health by reducing tobacco-related illnesses should be the top priority.
“One important component to achieving that is to enact policies that shift away from the most harmful tobacco products to less harmful alternatives. E-cigarette flavor restrictions have the opposite effect of pushing many people towards more harmful tobacco.”
