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E-cigarettes should be marketed as smoking cessation products

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The Food and Drug Administration (FDA) has just announced the formation of a new Nicotine Steering Committee to modernize the agency’s regulatory approach to nicotine replacement therapy products, noting that the new group might consider “changes to the labeling and indications for existing products…that might deliver nicotine at different rates,” in pursuit of policies that are “more helpful in helping smokers quit combustible cigarettes.” This is welcome news, as it shows a growing understanding that safer alternatives, including e-cigarettes, are available to smokers who want to quit.

Regulation of the many flavors offered on today’s market, though, has proven to be a dilemma in the murky politics surrounding vaping as policymakers grapple with its place in public health policy. This is despite the ever growing recognition that vaping can serve as a less harmful alternative to traditional tobacco products, and that flavors can help keep former smokers away from combustible tobacco products.

At his confirmation hearing earlier this year, FDA Commissioner Scott Gottlieb was questioned on how he would balance the key role flavors play in appealing to current vapers and the protection of non-smoking, young people susceptible to flavors’ allure when regulating e-cigarettes.

Gottlieb indicated he would look to the research community to inform the most appropriate regulatory model of e-cigarettes and e-liquid flavors. Other stakeholders, though, have called for e-cigarette flavors to be restricted to the two flavors offered by traditional combustible products, tobacco and menthol.

Part of the difficulty faced by Gottlieb and other policymakers in deciding the appropriate way to regulate e-cigarette flavors is that scientific research paints a complex picture. The U.S. government-funded Population Assessment of Tobacco and Health Study and the National Health Interview Study show clear evidence that frequent users of vaping devices are more likely to attempt to quit smoking and, moreover, show a greater likelihood that quit attempts will be successful.

These studies also show that frequent vapers were also the ones choosing to vape the non-tobacco flavored e-liquids. A recent online survey of frequent vapers in the U.S. showed that even those smokers who started vaping using tobacco flavored e-liquids rapidly shifted to the other flavors as they sought to distance themselves from the smoking experience. On this basis, flavors appear to be a significant factor in enabling smokers to move away from more harmful combustible tobacco products.

Alongside studies showing the positive impact of flavors, though, is mounting concern that the variety of appealing flavors offered may be a factor in attracting young people to start vaping. In one recent analysis, researchers from the Dartmouth Institute for Health Policy and Clinical Practice reported that young people who began vaping were between two to six times more likely than their non-vaping peers to have also started to smoke.

A study from the University of Michigan showed that non-tobacco flavored e-liquids were the ones most often used by young people. The results of these studies have led to calls to severely restrict the available range of flavors in order to reduce the appeal of e-cigarettes to young people.

However, we also know that restriction of flavors could come at the expense of smokers seeking a route out of their addiction through the use of e-cigarettes. With an estimated 35.5 million smokers in the United States, it is questionable whether the country can afford such a costly error in public policy.

Given the varying and at times conflicting research on the potential merits of e-cigarette flavors, policymakers should avoid the false dilemma of supporting the proliferation of ever more flavors or massively restricting flavors. Instead, regulators could work with manufacturers to reasonably reduce the number of flavors available in the future while retaining the range of flavors currently available.

At the same time, lawmakers could strengthen the penalties for those caught marketing and selling e-cigarettes to underage users.

There is yet another policy option to ensure the continued attraction of vaping devices to smokers seeking to quit and reducing the appeal of e-cigarettes to young people — allowing e-cigarettes manufacturers to market e-cigarettes as smoking cessation products. According to recent research, this is typically how e-cigarettes are being used, yet is the very thing manufactures are not allowed to claim under current law.

While such a change would require only a simple adjustment to the Tobacco Control Act, it would also require members of Congress to rise above the complicated politics surrounding e-cigarette use in favor of potentially enormous strides in ending America’s addiction to smoking.

Dr. Neil McKeganey is the director at the Centre for Substance Use Research in Glasgow, Scotland.


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