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Underage vaping spikes in the north of England

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Survey stresses role of vaping in tobacco control

https://manilastandard.net/business/biz-plus/321405/survey-stresses-role-of-vaping-in-tobacco-control.html

Results of a first-of-its-kind survey in India highlight the potential of e-cigarettes as an additional option for tobacco control and how vaping can have a substantial impact on public health.

Peter Paul Dator, president of The Vapers Philippines, said the groundbreaking survey in India clearly shows that vaping helps smokers quit or reduce smoking.

“Its results are particularly relevant to the Philippines because like India, our country has a large number of smokers and a low smoking cessation rate. The Department of Health and other local policymakers should look at the evidence for e-cigarettes with an open mind and start making science-based decisions to help reduce smoking in the country,” said Dator.

Dator was referring to the interview-based survey involving 3,000 vapers aged 18 and older from eight of the largest metropolitan cities in India. The vast majority of respondents (71.3 percent) used e-cigarettes to quit (30 percent) or reduce (41.3 percent) smoking.

Similar results were observed in smokeless tobacco users. Most (79 percent) believe that e-cigarettes are less harmful than combustible cigarettes. Survey participants reported minimal side effects (cough, headache, dry mouth/throat) and some health benefits (improved general health, breathing, smell and taste) after they started vaping.

Around 81 percent of survey respondents were men and 19 percent women, with average age of 29 years. The majority (80 percent) were first exposed to nicotine through combustible cigarette smoking, SLT use or both.

Leading tobacco harm reduction expert Dr. Konstantinos Farsalinos and Indian researchers conducted the survey whose results were published on March 30, 2020 in Harm Reduction Journal.

Dator said that India and the Philippines face similar smoking-related public health challenges. The World Health Organization estimates that there are over 120 million smokers in India, accounting for almost 12 percent of the 1.1 billion smokers globally.

The 2016-2017 Global Adult Tobacco Survey revealed that India has the second-lowest quit rate among GATS countries surveyed at the end of 2017. It also showed that India has the second-largest tobacco consuming population in the world, estimated to be over 267 million, which includes at least 100 million tobacco smokers and over 199 million SLT users.

Dr. Farsalinos and his co-authors said that tobacco-related deaths in India are estimated to be over 1 million a year and are projected to rise to 1.5 million by 2020. They also pointed to the prevalence of smoking-related illnesses such as heart disease, lung cancer and chronic pulmonary obstructive disease in India.

Dator cited DOH data, which show that almost 88,000 Filipinos die from smoking-related diseases every year. Healthcare expenditures and lost income due to smoking-related sickness and premature death cost the country P188 billion ($4 billion) yearly.

These figures only cover four of more than 40 smoking-related diseases namely lung cancer, chronic obstructive pulmonary disease, heart disease and stroke.

GATS found that there are currently 16 million Filipino adult smokers. “Like India, the Philippines has a very low smoking cessation rate of 4 percent. This dismal quit rate indicates the ineffectiveness of currently approved smoking cessation strategies in the country such as ‘quitting cold turkey’, counseling, and nicotine replacement therapy,” Dator said.

“We all know that the combustion in cigarettes is what is harmful to the health of smokers. The harm from smoking is caused primarily through the toxins produced by the burning or combustion of tobacco. By contrast, non-tobacco, non-smoked nicotine products such as e-cigarettes are considerably less harmful,” Dator said.

He cited the widespread agreement among organizations such as Action on Smoking and Health, Public Health England, Cancer Research UK, the Royal College of Physicians and the Royal College of General Practitioners that, on the basis of current evidence, e-cigarettes or vapes represent a significantly less harmful alternative to tobacco cigarettes for smokers who are unable or unwilling to stop using nicotine.

“The DOH should pay particular attention to how the study authors described India’s e-cigarette ban as a ‘missed opportunity’ and urged the Indian government to promote additional research and consider revising the regulatory framework if the evidence warrants it,” Dator said.

The Indian government banned the import, manufacture, sale, advertisement, storage and distribution of e-cigarettes in September 2019. According to Dator, India’s vaping ban is a tobacco control approach that other governments should not adopt.

“Such a retrogressive policy will be a major blow to smokers who have switched to vaping. It will likely push them to go back to smoking combustible cigarettes,” he said.

Streaming services flouting India’s regulations banning tobacco imagery in all media

Working with colleagues at HRIDAY (Health Related Information Dissemination Amongst Youth) in New Delhi, and WHO, we just published “Tobacco imagery in on-demand streaming content popular among adolescents and young adults in India: implications for global tobacco control” in Tobacco Control.

https://tobacco.ucsf.edu/streaming-services-flouting-india%E2%80%99s-regulations-banning-tobacco-imagery-all-media

Here is the press release BMJ sent out about the paper:

Streaming services flouting India’s regulations banning tobacco imagery in all media

Stronger enforcement needed, while WHO guidelines should be updated, say researchers

Streaming services that are popular with teens and young people in India are flouting the nation’s regulations on exposure to tobacco imagery in any media platform, reveals an analysis of 10 on-demand streaming series, published online in the journal Tobacco Control.

The rules, which are designed to protect young people, should be more rigorously enforced, and the guidelines for the implementation of Article 13 of the WHO Framework Convention on Tobacco Control should be updated to include streaming services and other new media, conclude the researchers.

Almost 266 million people aged 15 and older use tobacco in India, and the resulting health problems are “substantial,” say the researchers.

In response, India has strengthened its tobacco control efforts, particularly in relation to teens and young people who are highly susceptible to the effects of tobacco imagery, by banning the advertising and promotion of all tobacco products in every media platform.

And since 2012, any film or TV programme containing tobacco imagery must include prominent audio-visual anti-tobacco health warnings for specified periods of time, irrespective of whether it’s produced in India or elsewhere.

On-demand streaming services, such as Netflix, YouTube, Hotstar and Amazon Prime Video, have become increasingly popular among young people in India. The researchers therefore wanted to find out how much tobacco imagery is present in streamed content and how well streaming services comply with Indian tobacco control regulations.

They held focus group discussions with school and college students, aged 15 to 24, in New Delhi, to find out which streaming services they used the most and what they watched.

Based on these discussions, the researchers came up with the 10 most popular series, comprising 188 episodes. All but two of the series were streamed on Netflix; the rest were streamed on Amazon Prime Video. Only two of the series were Indian productions.

The 10 series were: The Marvellous Mrs Maisel (rated 16+); Stranger Things (16+); Bodyguard (16+); Riverdale (13+); Narcos (16+); Sacred Games (18+); Mirzapur (18+); Chilling Adventures of Sabrina (16+); 13 Reasons Why (16+); and The Crown (16+).

The researchers used a validated method (Breathe California) to count the number of tobacco incidents in each series. Incidents were defined as the actual or implied use of a tobacco product by an actor.

The analysis showed that 70% of the series depicted tobacco incidents which ranged from zero to 1652 in The Marvellous Mrs Maisel. More than half of the total number of episodes (57.4%) contained at least one such incident.

Narcos contained 833 incidents; The Crown 599; Stranger Things 233; Chilling Adventures of Sabrina 171; Mirzapur 78; and Sacred Games 67.

The Marvellous Mrs Maisel (18 episodes over two seasons) had the highest average number of tobacco incidents (87.5) per episode for the entire series, followed by The Crown (20 episodes over two seasons) with 29, and Narcos (30 episodes over three seasons) with 26.5.

Indian productions contained fewer tobacco incidents per episode and per hour than those produced elsewhere.

Four out of the 10 series depicted tobacco brands, including Mayburn, Camel, Marlboro, Salem and Newport. All these series were foreign productions.

But none of the series that included tobacco incidents complied with the tobacco-free film and TV rules in India.

Their analysis suggests that the extent of tobacco imagery and brand placement in on-demand streaming service content in India is high, while compliance with the rules is low, say the researchers.

“There is no reason to expect that the effects of exposure to tobacco imagery in streaming shows should be any different than the effects of tobacco imagery in films,” they write.

“On-demand streaming content providers and governments should heed the lessons learnt from the film industry and apply the same rules to include tobacco imagery in the content available through on-demand streaming platforms,” they add.

And it’s clear that the legislation “is blatantly being violated in this new media, indicating the need for better enforcement of existing rules in India and updating the guidelines for implementation of Article 13 of the WHO Framework Convention on Tobacco Control,” they conclude.

Here is the abstract:

Background India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure.

Objective To assess tobacco imagery in online series popular among adolescents and young adults.

Methods Ten popular online series on streaming platforms were identified after discussions with participants (aged 15–24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded.

Results 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon’s ‘The Marvellous Mrs Maisel’ (87.5, IQR 62.0–116.0) and Netflix’s ‘The Crown’ (29.0, 18.0–36.0) were higher than Indian productions: Netflix’s ‘Sacred Games’ (9.0, 0.5–14.5) and Amazon’s ‘Mirzapur’ (7.0, 4.0–11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules.

Conclusion Contrary to Section 5 of India’s Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.

What this paper adds

Section 5 of India’s Cigarettes and Other Tobacco Products Act (COTPA) imposes a complete ban on tobacco advertising and promotion in any form of media.
Streaming is a new form of media popular among adolescents and young adults in India.
We found that out of the 188 episodes across 10 on-demand streaming series studied, the US produced series – Amazon’s ‘The Marvellous Mrs Maisel’ and Netflix’ ‘Narcos’ and ‘The Crown’ had higher tobacco imagery compared with Indian produced series – Amazon’s ‘Mirzapur’ and Netflix’ ‘Sacred Games’.
Section 5 of COTPA is blatantly being violated in this new media indicating the need for better enforcement of existing rules in India and updating WHO Framework Convention on Tobacco Control Article 13 guidelines.
The full citation is: Arora M, Nazar GP, Chugh A, Rawal T, Shrivastava S, Sinha P, Munish VG, Tullu FT, Schotte K, Polansky JR, Glantz SA. Tobacco imagery in on-demand and streaming content popular among adolescents and young adults in India: implications for global tobacco control. 2020; epub ahead of print 9 Apr 2020 doi 10.1136/tobaccocontrol-2019-055360. It is available here.

This item is cross-posted from the Smokefree Movies blog entry, which is here.

Third of NZ students have tried vaping, despite most being non-smokers

http://www.voxy.co.nz/health/5/361613

New research shows that more than a third of New Zealand high school students have tried vaping even though nearly two-thirds of those doing so have never smoked cigarettes.

Vapes, or electronic cigarettes, are not recommended for non-smokers, as the long-term effects are not known, and vapes containing nicotine are likely to be addictive.

“Vaping is not as harmful as smoking, but it is not harmless. Taking up vaping is not a good idea for people who are not otherwise smokers, particularly young people,” says study co-author Dr Terry Fleming from Te Herenga Waka-Victoria University of Wellington’s School of Health.

The study is the first in New Zealand to look at vaping in high school students of all ages. It found 65 percent of teenagers who had tried vaping reported they had never smoked cigarettes, as well as 48 percent of those who said they vaped regularly. Overall, 38 percent of teenagers reported they had tried vaping, 10 percent said they vaped regularly, and 6 percent vaped weekly or more often.

The research also shows vaping is relatively common for students in all school deciles, whereas smoking is now rare in higher decile schools.

“Vaping seems to appeal to a wider range of young people than smoking and unlike smoking it is more common in boys than girls,” says Dr Fleming.

Recently published data from another New Zealand study shows the long-term decline in smoking among Year 10 students that began in 2000 stalled from about 2015 and may even be reversing, particularly in MÄori and low decile schools.

“When you put these findings together, it calls into question the idea that vaping is displacing smoking. The alternative possibility, that vaping is fuelling smoking, must be taken seriously by communities and policymakers,” says study co-author Associate Professor Terryann Clark from the University of Auckland.

Researchers say measures to protect youth, particularly MÄori and disadvantaged youth, from both vaping and smoking harm are needed, such as limits on where vapes and tobacco can be sold and a ban on vaping advertising and sponsorship, including online and social media promotion.

The research is timely, as the Government is currently consulting on new vaping regulations announced earlier in the month.

“New Zealand has fewer restrictions on promoting vaping and on vape flavours than many other countries. Supporting smokers to step down to vaping and non-smokers to stay that way are both important-this is possible with good policy and leadership,” says Dr Fleming.

The research is part of the Youth19 survey, which aims to collect data on a range of issues affecting New Zealand youth. Further results from the survey will be available over the coming year. This survey is a collaboration between Te Herenga Waka-Victoria University of Wellington, the University of Auckland, the University of Otago, and AUT.

Analyzing big tobacco’s global youth marketing strategies

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Quit smoking immediately to reduce the risks of COVID-19

https://www.smokefree.hk/en/content/web.do?page=news20200331

In view of the latest epidemic development of Coronavirus Disease 2019 (COVID-19) across the globe, Hong Kong Council on Smoking and health (COSH) advised the general public to stop using any kinds of tobacco products including conventional cigarettes, electronic cigarettes, heat-not-burn tobacco products and waterpipe tobacco immediately. Mr Antonio KWONG, COSH Chairman said, “Study of COVID-19 cases revealed that smokers are associated with higher risk of getting severe symptoms than non-smokers. Also, smoking at home increases the risk of secondhand smoke (SHS) exposure among family members, especially young children. COSH reminded the public not to initiate smoking and smokers must quit smoking now to safeguard their health.”

There is a misleading claim that “smoking could help prevent COVID-19”. The World Health Organization had already clarified that the statement is false, and scientific evidence has also emerged to show that smoking may increase the risk of the infection. According to a review study on COVID-19 cases in China, smokers were 1.4 times more likely to have severe symptoms of COVID-19 and approximately 2.4 times more likely to be admitted to an Intensive Care Unit, need mechanical ventilation or die compared to non-smokers. Since smokers are unable to wear a surgical mask or avoid contact with the mouth and nose while smoking, it might increase the risk of spreading COVID-19 and viral infection.

According to COSH’s Tobacco Control Policy-related Survey conducted from February to June 2018, among all respondents, 15.1% lived with at least one smoker and 13.8% reported SHS exposures at home in the past seven days. Evaluation Study on “School Interactive Education Theatre Programme 2018-2019” reflected that 34.6% of children exposed to SHS at home in the past seven days. Members of the public are urged not to smoke at home to protect family from SHS exposure, as well as to minimize the risk of smoking-related fire accidents while staying home for prevention of COVID-19.

Some of the recent confirmed COVID-19 cases in Hong Kong traced to visits to bars, expert in communicable diseases warned that the use of waterpipe tobacco in bars might increase the risk of infection transmission among users. Smoke of waterpipe tobacco contains numerous toxicants including tar, carbon monoxide, heavy metals and carcinogens. A research found that one-hour waterpipe smoking session exposes the user to 100 to 200 times the volume of smoke inhaled from a single cigarette. COSH emphasized that there is no safe and harmless tobacco product. All people should reduce social activities, maintain good personal hygiene and develop healthy habits for reduction of disease risk. COSH highly recommended smokers to stop smoking as soon as possible to maintain a healthy lifestyle. Smokers can call the Integrated Smoking Cessation Hotline (Department of Health) 1833 183 for professional assistance if necessary.

Raise Hong Kong tobacco tax to protect youth against lifelong addiction

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ENDs products no safer than cigarettes- generate dual users – designed to keep youth and adults addicted to nicotine

Dear Panel members,

the enhanced addictiveness of RECON used exclusively in iQos HEETS

iQos Heets use cast leaf technology aka RECON (reconstituted tobacco)

The veins, stalks and stems, leaf dust (named OFFAL) from the cigarette production process are mixed with chemicals in a slurry to create a Recon sheet.

https://startobacco.biz/reconstituted-tobacco/

The manufacturer can fine tune the addictiveness of the RECON product and using a smaller amount of RECON.

http://www.jeffreywigand.com/theinsider.php

see The Insider Dr Wigand’s expert report under –‘Testimonies’ – ‘Dr Wigand’s WHO Expert Report’

Search the report for ‘Recon’

The Report is eye opening and informatory.

For your ease of reference I attach some sections on RECON from the WHO Expert report:

Quote:

“The use of RECON is the one of the principal methods of introducing acid base ammonia  chemistry and other additives into the USB non-menthol cigarette blend. RECON can be  considered a chemical-additive delivery system in addition to the casing process of tobacco.  Ammonia chemistry is utilized for several reasons; 1) to scavenge nicotine from each blend  component; 2) to equalize the concentration of nicotine in the tobacco column rod; and 3) to modify pH such that nicotine becomes a free base.

Free nicotine, which is controlled by smoke pH, is a more potent form of nicotine that is in the gas phase rather than bound nicotine that is in  the particulate phase.  The extensive use of ammonia chemistry in RECON converts the salt  linked or protonated nicotine into “free” nicotine that has a higher potency than its salt/protonated form.  Free nicotine it is not detected by the smoking machine analysis of tar and  nicotine since it is in the gaseous state not in the particulate state of matter.

The primary importance of RECON is neither the utilization of manufacturing waste nor  the enhancement of economy of manufacture.  Rather, RECON is important because it  introduces a significant amount of additives into the cigarette blend. These additives accomplish  two distinct purposes: 1) they increase the addictive capacity of the cigarette and 2) they facilitate the ease of smoking by ameliorating the effects of inhaling smoke.

 RECON tobacco comprises about 20-30% of a USB cigarette’s blend formulation on a  w/w basis.  It is a chemically manipulated material using abundant additives, such as glycerol, licorice, cocoa, honey, polyethyleneglycol (PEG), simple sugars, invert sugars and ammonia based additives such as ammonium hydroxide, urea and diammonium hydrogen phosphate  (DAP). The ammonia based additives in RECON play a key role in the manipulation of nicotine.

The finished product is a highly energized chemical matrix which forms the basis of many of the  chemical reactions occurring in the tobacco rod column, such as nicotine scavenging, generation of free nicotine, smoke pH manipulation, and formation of some flavor reaction products.

  1. Raw material components and composition of RECON

RECON is produced utilizing by numerous by-products of the cigarette manufacturing process.  There are three (3) distinct RECON types; Paper I, Paper II and band cast. The raw material used to make RECON contains the following components:

1) Offal or the tobacco dust generated in either the Green Leaf Trashing (GLT) plant or in the Primary manufacturing process.  The GLT Plant strips and removes the veins of the tobacco leaf into large strips of lamina and produces a by-product called stems.  Stems can be utilized either as a cigarette blend component or as one of the sources of raw material for RECON.

 

2) The primary portion of the manufacturing plant produces the fines and winnowers when tobacco, a moisture sensitive biomaterial is moved rapidly through the

manufacturing process, either pneumatically or via high-speed conveyor belts. This aspect of the manufacturing process causes dehydration and brittleness of the tobacco material, and therewith the formation of tobacco fines and dust (offal).

3) Stems produced at the GLT Plant

4) Tobacco fines or winnowers

5) Product Reclaim.  Finished product that is collected from the distribution channel is returned to the manufacturing plant for reprocessing.  This includes the finished goods that, due to moisture content loss, are deemed unsuitable for smoking due to increased irritation, harshness and the fact that they pose a fire hazard.

 6) Unique tobacco cultivars are used either to augment nicotine content or to augment or enhance flavor attributes of the final RECON product.

 7) Cellulosic material from wood pulp added for fiber content

 3. Band cast reconstituted tobacco (Dark RECON)

Band cast uses the same starting raw materials but differs fundamentally from the paper  making RECON process. Unlike the paper process, band cast is made by adding the stock raw  tobacco materials (see list above) and prescribed chemical additives into one reaction vessel. 

The tobacco material is then pulverized with the additives forming a thermally and chemically reacted slurry mixture.  The sheet is made by pouring the slurry into a “doctor blade” which  regulates the amount of slurry that is applied to a moving S/S non-perforated belt.  The basis weight can be controlled at this point.

The slurry mixture then goes through three separate heating zones where the water content is reduced forming a solid sheet.  This solid sheet is then cut into irregular pieces and boxed in a similar manner to the paper RECON.”

 

See also

https://www.who.int/news-room/q-a-detail/q-a-on-smoking-and-covid-19

Kind regards,

James Middleton

Chairman

Clear the Air NGO

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South Korean court delivers latest blow to e-cigarette makers

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Regulating Vaping — Policies, Possibilities, and Perils

https://www.nejm.org/doi/full/10.1056/NEJMp1917065

Smoking rates peaked in the United States in the mid 1960s and have since declined to historically low levels. In contrast, use of e-cigarettes has recently soared, particularly among young people. In 2019, more than 27% of high school students reported using e-cigarettes during the past month, as compared with about 6% who reported using combustible cigarettes.1 Use of Juul products accounts for much of the doubling of vaping rates between 2017 and 2019, and these products represent 75% of the multibillion-dollar e-cigarette market. The growth in vaping among young people has alarmed policymakers and many others.

Federal and state governments have implemented numerous policies to combat the growth of vaping. To promote the health of the population, however, policies should protect young people without diminishing the ability of e-cigarettes to help adult smokers transition away from more harmful combustible cigarettes or to serve as a cessation aid for people attempting to quit smoking. This tension presents a quandary for policymakers, since vaping policies often promote one goal at the expense of the other. Furthermore, the facts that certain state and federal policies complement, substitute for, or undermine each other and that some federal policies supersede state policies add another layer of complexity to policymaking in this arena.

Because e-cigarettes vaporize liquid instead of burning tobacco, they are generally thought to be less harmful than combustible cigarettes.2 However, the long-term health effects of inhaling liquid flavoring chemicals and nicotine are unknown.

Juul is a cartridge (“pod”) type of e-cigarette — it is a reusable, rechargeable device that holds a liquid-containing pod, rather than a refillable open-tank system or a disposable device. Juul pods contain higher levels of nicotine than many other e-cigarette products, which makes them a better substitute for combustible cigarettes for smokers. However, high nicotine levels increase the risk of addiction among young people and can harm their cognitive development. Vaping e-cigarettes adulterated with tetrahydrocannabinol (THC) and vitamin E acetate recently caused an outbreak of acute lung disease and deaths.3 Although these harms are seemingly linked to the addition of THC and to the use of e-cigarettes obtained from informal sources rather than to e-cigarettes in general, these complications heighten concerns about e-cigarettes.

Capture5

State and federal policymakers are focusing on two key policies for preventing vaping among young people: minimum sales age laws that restrict the sale of e-cigarettes to adolescents and bans on flavored e-cigarettes. Some states have also implemented e-cigarette taxes (see table).

In December 2019, Congress passed so-called Tobacco 21 legislation, which immediately sets a federal minimum age of 21 for purchasing tobacco products, including e-cigarettes. Twenty-four states and the District of Columbia had enacted policies that set the minimum age for purchasing e-cigarettes at either 19 or 21; in other states, the minimum age was 18.

Because most tobacco use begins before 19 years of age, the new federal law has the potential to dramatically reduce current tobacco use among young people and prevent some people from ever using tobacco. However, enforcing bans on sales to minors is difficult in retail locations and even more so online, and young people often obtain e-cigarettes from family members and friends. To reduce access to e-cigarettes among young people, federal and state governments could increase funding for enforcement efforts and collaborate to find better ways to prevent sales to young people in stores and online.

Another important policy is banning flavored e-cigarettes. Because flavors are more attractive to young people than to adults, a flavor ban could reduce the appeal of e-cigarettes for young people without diminishing their role in harm reduction for adult smokers. Nine states have passed flavor bans, but most have been short-term emergency bans or have been blocked by legal challenges.

In December 2019, the Food and Drug Administration (FDA) announced that it will use its market-review authority to essentially ban all flavors except tobacco and menthol in cartridge (pod-based) e-cigarettes. These changes became effective in February 2020. Disposable e-cigarettes and e-liquids for open-tank–system e-cigarettes typically sold in vape shops are not covered by the policy. The effect of the ban may be limited because of these important exemptions.

Banning all flavors in all tobacco products with few or no exemptions could be more effective than the current narrow ban for several reasons.4,5 First, menthol cigarettes, which remain on the market, have been shown to be appealing to young people. Second, although young people prefer fruit- and candy-flavored pods to menthol-flavored pods, the latter might become more attractive if they are the only flavored pods available. Third, under the current ban, young people may switch to e-cigarettes that are still permitted to contain flavoring. Indeed, adolescents have recently been favoring new flavored, disposable e-cigarettes that resemble Juul devices but have higher nicotine concentrations and cost less.

Another concern is that it is unclear how committed the FDA is to enforcing the flavor ban for cartridge e-cigarettes. The agency has largely declined to act on its authority to regulate e-cigarettes and to fulfill an obligation established by Congress to force products that do not protect public health, such as Juul devices, off the market. State bans on flavored e-cigarettes may therefore still be important.

A final policy is taxation of e-cigarettes. Twenty-one states and the District of Columbia tax both e-cigarettes and combustible cigarettes; the federal government taxes only combustibles.

The effects of such taxes on public health are complicated for several reasons. Levying taxes on e-cigarettes raises their price, thereby deterring some people from vaping. However, such taxes will also drive some vapers toward smoking, since taxes tend to increase the price of e-cigarettes relative to the price of combustibles.4,5 Consequently, the tax rate on e-cigarettes should be set so that it is cheaper to vape than to smoke. Determining optimal tax rates is complicated by the multiple types of e-cigarettes available, the fact that devices and pods are often bought separately, and the ability of companies — not the government — to set prices. Furthermore, too high a tax on e-cigarettes will encourage vaping of lower-priced or black-market e-cigarettes, thus undermining the benefits of the tax.

Given these considerations and the lack of evidence regarding how people respond to taxes on e-cigarettes, it may be preferable to rely on greater enforcement of Tobacco 21 policies and flavor bans to prevent vaping among young people. The appeal of tax revenue, however, may be too strong for governments to resist.

But at what level of government — state or federal — should e-cigarette policies be implemented? There are several advantages to states taking the lead. States may be more nimble regulators than the federal government, each state can regulate to meet its own needs, and state policies can serve as experiments and generate useful evidence. State laws can fill voids when federal regulations are absent or ineffective. States can also provide an impetus for federal action by demonstrating nationwide political will, as they did by passing Tobacco 21 laws. However, differing state policies risk leaving young people in some states unprotected and promoting the flow of e-cigarettes across state lines.

On the other hand, implementing regulations at the federal level has potential advantages over relying on state-based regulation of e-cigarettes because of the broad reach of national policies and their capacity to reduce trafficking across state borders. Nevertheless, as compared with states, the federal government has been slow to implement certain regulations.

Soaring rates of vaping among young people and associated problems have resulted in great urgency and important challenges for policymakers. Despite the urgency, policies should be evidence-based and thoughtfully designed. They require effective, collaborative, and well-funded enforcement by federal and state governments. Policymakers should aim to reduce vaping among young people while maintaining avenues to help smokers quit. Finally, policies should be forward-thinking, since the e-cigarette market is rapidly changing and e-cigarette companies can be more agile than regulators.