In early 2020, the Food and Drug Administration (FDA) banned “certain unauthorized flavored e-cigarette products that appeal to kids, including fruit and mint flavors.”1“FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint,” U.S. Food and Drug Administration, January 02, 2020. [Online]. Available: https://www.fda.gov/news-events/press-announcements/fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children.This crackdown marked one of the FDA’s firmest attempts to stop young people from vaping. It also sparked the idea that e-liquid flavorings might be dangerous in themselves.
One report redirects the conversation away from teenagers and instead focuses on how flavored e-liquids benefit smokers who want to kick the habit for good. The report, “The Case for Flavours in Tobacco Harm Reduction, To Save Lives”2Konstantinos Farsalinos, MD, MPH, “The Case for Flavours in Tobacco Harm Reduction, To Save Lives” FARSALINOS Flavours in Tobacco Harm Redution Review 2023, was written by Dr. Konstantinos Farsalinos and first published in 2022, and has since been rereleased in 2023. Dr. Farsalinos, who is a cardiologist and research fellow at the Onassis Cardiac Surgery Center in Athens-Greece, draws on 343 references to come to the conclusions outlined in his 96-page report.
In the report, Dr. Farsalinos concludes “It is clear that flavoured nicotine vaping products are instrumental in aiding adult smokers in their quest to quit smoking cigarettes. In my view, legislators should seriously take this into account, especially when they start considering the regulation of flavour in ENDS.”
In terms of preventing youth initiation, Dr. Farsalinos has three main ideas.
- Bans at points of sale
- Marketing bans, for those marketing practices clearly targeting the youth
- More research into proven policies that minimize marketing to children
Dr. Farsalinos does not agree with the premise that banning e-liquid flavors stops youth initiation. Instead, he encourages lawmakers and researchers to “conduct wide-ranging consumer perception and behavioral studies to determine and help validate the role and effectiveness of flavours”.
So, why the FDA decide to focus on flavored e-liquids? In a 2019 survey titled “Tobacco Product Use and Associated Factors Among Middle and High School Students”3Teresa W. Wang, PhD; Andrea S. Gentzke, PhD; MeLisa R. Creamer, PhD; Karen A. Cullen, PhD; Enver Holder-Hayes, MPH; Michael D. Sawdey, PhD; Gabriella M. Anic, PhD; David B. Portnoy, PhD; Sean Hu, DrPH; David M. Homa, PhD; Ahmed Jamal, MBBS; Linda J. Neff, PhD “Tobacco Product Use and Associated Factors Among Middle and High School Students—United States, 2019,” Centers for Disease Control and Prevention, December 6, 2019. [Online]. Available: https://www.cdc.gov/tobacco/data_statistics/mmwrs/byyear/2019/ss6812a1/index.html, researchers asked middle and high school students their top reasons for trying e-cigarettes.
- Curiosity (55.3%)
- A friend or family member used e-cigarettes (30.8%)
- Availability of flavors like mint, candy, or chocolate (22.4%)
- They wanted to use e-cigarettes to perform tricks (21.2%)
This research could be part of the FDA’s decision-making process, but some argue that the 2020 ban buried the lead. After all, there are other, more pressing concerns to think about, as Michael Joseph Blaha, M.D., M.P.H, a cardiologist at Johns Hopkins University, argues. He claims that some of the additives found in e-liquids are dangerous and even deadly4Michael Joseph Blaha, M.D., M.P.H “Vape Flavors and Vape Juice: What You Need to Know,” Johns Hopkins Medicine, [Online]. Available: https://www.hopkinsmedicine.org/health/wellness-and-prevention/vape-flavors-and-vape-juice-what-you-need-to-know. He points out that vitamin E acetate, a condensing agent commonly found in e-liquid, is associated with lung injuries. Despite this, the substance has not been banned in the US5F. B. Boudi, S. Patel, A. Boudi, and C. Chan, “Vitamin E Acetate as a Plausible Cause of Acute Vaping-related Illness,” Cureus, vol. 11, no. 12, Dec. 2019. [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952050/.
This is not the first time the FDA’s action have come under scrutiny. Recently, we wrote about the FDA’s track history of sending warning letters to manufacturers that market to children and its subsequent failure to follow through with any consequences.
Some might argue that the FDA’s time would be better spent by banning substances that are proven to be dangerous, such as vitamin E acetate, and implementing real consequences for manufacturers that continue to market to children.
