Legal restrictions on the flavors of nicotine vaping products are associated with increased cigarette purchases, according to a new paper that analyzes retail sales data from 44 states. For each fewer 0.7-milliliter nicotine pod sold in jurisdictions with such policies, the analysis found, consumers bought 15 more cigarettes. "That tradeoff," the authors note, "equates to over a pack more cigarettes per pod for the size of current leading products" such as the Vuse Alto, which uses 1.8-milliliter pods.
The substitution effect identified by this study underlines the folly of trying to protect public health by deterring the use of electronic nicotine delivery systems (ENDS), which are far less hazardous than combustible cigarettes. "We find that ENDS flavor policies reduce flavored ENDS sales as intended, but also increase cigarette sales across age groups," Yale public health researcher Abigail Friedman and her collaborators report. "As cigarettes are much more lethal than ENDS, the high rate of substitution estimated here suggests that, on net, any population health benefits of ENDS flavor policies are likely small or even negative."
Friedman et al. identified 15 state and 279 local flavor restrictions that took effect during the study period—January 7, 2018, through March 26, 2023. Those policies included both outright bans on ENDS flavors other than tobacco and laws that limited sales of such products to specialty stores such as vape shops and tobacconists. The study's sales data came from Information Resources Incorporated, which collects checkout numbers from convenience stores, supermarkets, drug stores, discount stores, and gas stations.
"ENDS sales fall and cigarette sales rise as a greater percentage of state residents is subject to policies restricting flavored ENDS sales," Friedman et al. report. "Effects are in the same direction for policies prohibiting all ENDS sales (i.e., flavored and unflavored), consistent with substitution." These effects are "larger in the long-run; that is, for policies in effect a year or longer," the researchers note. They add that "separating ENDS flavor prohibitions from less restrictive policies limiting flavored ENDS sales to particular types of retailers reveals that both policies yield reductions in ENDS sales and increases in cigarette sales once in effect for at least a year."
The relationship between reduced ENDS sales and increased cigarette sales, the study found, "holds across cigarette product age profiles, including for brands disproportionately used by underage youth." Menthol brands accounted for 29 percent of the increase in cigarette sales, while standard cigarettes accounted for 71 percent, which "indicates that the observed substitution response to ENDS flavor policies cannot be attributed to menthol cigarettes' availability" or "fully counteracted by menthol cigarette sales prohibitions."
These findings, Friedman et al. note, are consistent with "results from 16 of 18 other studies assessing cigarette use following adoptions of minimum legal sales age laws for ENDS, ENDS tax rate increases, and advertising restrictions." They are also consistent with prior studies suggesting that ENDS flavor restrictions boost smoking rates. "In other words," the authors say, "policies making ENDS more expensive, less accessible, or less appealing appear to incentivize substitution towards cigarettes."
Who could have predicted that? Lots of people, starting with all the ex-smokers who have switched to vaping and overwhelmingly prefer the flavors that politicians portray as an intolerable threat to the youth of America. Savvy tobacco control experts likewise have been warning legislators and regulators for years that policies aimed at discouraging underage vaping could inadvertently lead to more smoking-related diseases and deaths.
The Food and Drug Administration (FDA), which provided some of the funding for this very study, concedes the harm-reducing potential of ENDS. Yet it has systematically undermined that potential by refusing to approve vaping products in flavors other than tobacco. As Friedman et al. note, the FDA "has only approved 23 ENDS products for
marketing to date, none of which are flavored." Although "flavored ENDS products remain widely available in states that do not prohibit their sales," they add, the FDA seems to be "paving a path towards a de facto national ENDS flavor prohibition."
The FDA is doing that in the name of public health. Yet its calculus of the impact from prohibiting ENDS flavors that former smokers demonstrably want does not take into account the sort of substitution described in this study. In its zeal to combat adolescent nicotine addiction, the FDA is willing to sacrifice the interests, and perhaps the lives, of adults who have already switched to vaping or might be interested in doing so.
There is an economic rationale for addressing the "internalities" of underage vaping through flavor restrictions, Friedman et al. concede, "particularly if youth do not anticipate nicotine addiction's impact on future cessation attempts." But that approach, they say, involves an "inequitable tradeoff," since it "prioritizes youth over the 11.2% of US adults [who] smoke." They note "evidence that ENDS use is more effective for smoking cessation than nicotine replacement therapy" and research indicating "high rates of 'accidental quitting' among smokers [who] try ENDS without intending to quit cigarettes."
They might have added that, whatever the long-term impact of underage vaping, it is bound to pale next to the smoking-related morbidity and mortality that could be avoided through wider use of ENDS. And that potential benefit applies even to people who start vaping as teenagers, to the extent that they would otherwise be smoking—another substitution effect that the FDA refuses to consider in deciding which nicotine products are "appropriate for the protection of public health."
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