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May 10th, 2016:

Canada: Plain Packaging For Tobacco Products

Plain packaging for tobacco products may soon be implemented in Canada. Plain packaging in this context means that tobacco company brand elements consisting of colours, logo and design elements of the brand will not be allowed to be used on product packaging. However, there are potential conflicts between government and suppliers and manufactures of tobacco products. The issues are becoming increasingly politicized.

The Supporters

The World Health Organization is actively lobbying to support the implementation of plain packaging. They have prepared and posted on their website an evidence brief.1

An abstract of their position is set out below:

“Evidence shows that the packaging of tobacco products is designed for badge products targeting specific groups, particularly women and young people, and that attractive packaging tends to weaken warnings about the harmful health effects of the products. To preserve the effectiveness of the health warnings – a requirement under Articles 11 and 13 of the WHO Framework Convention on Tobacco – the guidelines on the implementation of these articles recommend the adoption of plain-packaging measures.

Studies have revealed that plain packaging reduces the attractiveness of the product, particularly to women and young people. They also show that, when combined with large pictorial health warnings, plain-packaging measures increase awareness about the risks related to tobacco consumption, encouraging more people to quit and fewer to start. In that these measures merely regulate the use of logos or colours for public health purposes, they are in compliance with international trade and intellectual property law.”

The Canadian Cancer Society is also highly energized concerning this issue and has caused a video to be prepared and posted on its website. They suggest that there is increasing global momentum to implement plain packaging for tobacco products,

“Plain packaging is an important and logical next step for Canada to curb tobacco marketing, reduce smoking and save lives,” says Rob Cunningham, Senior Policy Analyst, Canadian Cancer Society. “Cigarette packages should not be minibillboards promoting tobacco use. We urge Health Canada to follow the lead of Australia and other countries and take action to implement plain packaging in order to reduce the appeal of these cancer-causing products.”2

The Opposition

Tobacco companies have actively opposed and attacked plain packaging legislation. Philip Morris Asia challenged the Australian tobacco plain packaging legislation under the 1993 Agreement between the Government of Australia and the Government of Hong Kong for the Promotion and Protection of Investments. However the panel hearing the dispute, on 18 December 2015 issued a unanimous decision finding that it had no jurisdiction to hear Philip Morris Asia’s claim.

Honduras requested consultations under the World Trade system with Australia concerning the Australian laws and regulations that impose trademark restrictions and other plain packaging requirements on tobacco products and packaging. Honduras claims that Australia’s measures appear to be inconsistent with Australia’s obligations under the TRIPS Agreement, among other grounds.

A panel has been established to hear the dispute. Argentina, Brazil, Canada, Chile, China, Cuba, the Dominican Republic, Ecuador, the European Union, Guatemala, India, Indonesia, Japan, Korea, Malawi, Malaysia, Mexico, New Zealand, Nicaragua, Nigeria, Norway, Oman, Panama, Peru, the Philippines, Singapore, South Africa, Chinese Taipei, Thailand, Turkey, Ukraine, the United States, Uruguay, Zambia and Zimbabwe have reserved their third-party rights. The panel expects to issue its final report to the parties not before the first half of 2016. Similar proceedings have been initiated by Ukraine, the Dominican Republic, Cuba and Indonesia.

The International Trademark Association (“INTA”) has submitted an amicus brief to the panel. INTA contends that the plain packaging measures implemented by Australia erode internationally protected IP rights under the Paris Convention, the Trans-Pacific Partnership (“TPP”) Agreement and other agreements.

In addition to the above tobacco companies can attack relevant legislation implementing plain packaging on the basis that such legislation does not comply with domestic legislation. For example in 1995, the Supreme Court of Canada struck down provisions of the Tobacco Products Control Act that broadly prohibited all advertising and promotion of tobacco products, subject to specific exceptions, and required that unattributed warning labels be affixed on tobacco product packaging, as contrary to Charter of Rights and Freedoms.

The Government Position

In response to these proceedings a number of governments have commenced a campaign to preclude tobacco companies from initiating investor-state dispute settlement proceedings under the relevant treaties. For example, the recently concluded TPP contains the following provision:

“A party may elect to deny the benefits of Section B of Chapter 9 (Investment_ with respect to claims challenging a tobacco control measure of the Party. Such a claim shall not be submitted to arbitration under Section B of Chapter 9 (Investment) if a Party has made such an election. If a Party has not elected to deny benefits with respect to such claims by the time of the submission of such a claim to arbitration under Section B of Chapter 9 (Investment), a Party may elect to deny benefits during the proceedings. For greater certainty, if a Party elects to deny benefits with respect to such claims, any such claim shall be dismissed.”

The Canadian Position

The recently elected Liberal government has indicated that it plans to force tobacco companies to sell their cigarettes in packages that lack distinctive brand designs aimed at enticing smokers to buy their products. This was part of an election promise and has now been escalated to a part of the mandate of the Health Minister. This mandate seems to be a top priority for a majority government.

At the present time there is no indication how quickly the government will move, or when the necessary legislation or regulations will move forward.

2 Media release dated October 4,2015 at

Flavorings in electronic cigarettes are hazardous to very young children

HealthDay News published a report by Randy Dotinga on May 9, 2016 noting the dangers of the nicotine in the liquid “juice” of electronic cigarettes (e-cigs). The title of the article is “E-Cigarette Poisonings Skyrocket Among Young Kids: Study”. The study showed that children under six were at the greatest risk. The study of the dangers of nicotine in e-cig liquids for small children was led by Gary Smith, director of Nationwide Children’s Hospital’s Center for Injury Research and Policy. The center is located in Columbus, OH. Smith had this to say about the conclusions of the study.

If this were an infectious disease, this would be headlines across the country . He noted that the number of e-cigarette exposures in kids jumped 1,500 percent from 2012 to 2015. E-cigarettes and liquid nicotine can cause serious poisoning, and even death, among young children. Like other dangerous poisons, they should be kept out of sight and reach of children, preferably in a locked location.

The FDA has taken responsibility for controlling all forms of tobacco, including e-cigs, cigars, hookahs, and e-cig liquids. The FDA has not extended their control of e-cig juice to eliminate the flavorings in e-cigs, which has been done for normal tobacco cigarettes. The flavorings in e-cigs are directed towards children in middle school and high school. It is these flavorings that also attract babies and primary school children. Flavor categories include tobacco, menthol, fruits, desserts, coffees, and cigars from one supplier. Tobacco cigarettes are prohibited from all flavorings except tobacco and menthol since 2009. The exception of menthol from the prohibited flavors list for cigarettes is a result of direct lobbying by the tobacco industry on the FDA. FDA studies indicate that menthol is a flavoring agent, and the FDA has still failed to eliminate flavoring agents from e-cigs.

When the FDA issued the new regulations on e-cigs and other forms of nicotine delivery, it said that more research was needed to determine the dangers of these products. This is a stalling tactic. There is absolutely no scientific ambiguity that nicotine is a poison, causes cancers of the kidney, liver and bladder, and contributes to lung and heart disease by constricting the vascular system. The Public Health Law Center has concluded that the flavorings are an attempt to create a new generation of tobacco users.

Studies show that flavored tobacco products appeal to youth, who are an enticing target market for the tobacco industry. The younger individuals are when they begin to use tobacco, the more likely they will become addicted to nicotine. For example, among adults who smoke, 68 percent began smoking regularly at age 18 or younger.

Tobacco users (particularly youth) often mistakenly assume that flavored tobacco products are safer than other tobacco products.

There needs to be an acceleration of the regulation to eliminate all flavorings in e-cigs that contain nicotine, and a prohibition of e-cig advertising that is as stringent as for tobacco cigarettes. The labeling of e-cigs should include a warning that smoking e-cigs can lead to addiction to nicotine and a substantial health risk due to the effects of nicotine.

The director of the FDA’s Center for Tobacco Products is Mitch Zeller, J.D. E-mails should be directed to, attention Mitch Zeller, Director. The phone number is 1-877-287-1373 from 9:00 a.m. to 4:00 p.m. Eastern time. More information about the Center for Tobacco Products is available on the internet. Direct inputs to the director’s office will influence the timing of decisions to regulate e-cig flavors to decrease the appeal of the e-cig liquids to children and young adults.

China’s cigarette sales fall slightly after tobacco tax: WHO

BEIJING Cigarette sales in China fell slightly over the past year after a hike in tobacco taxes, the World Health Organization said on Tuesday, as the country works to suppress a habit with major healthcare costs.

The world’s largest producer and consumer of cigarettes has stepped up its battle on smoking, despite persistent opposition from the tobacco industry.

China has 300 million smokers and 740 million more who are exposed to secondhand smoke, state media have said.

The number of cigarettes sold in China fell 3.3 percent in the year to March 2016 from the previous year, the WHO said in a statement.

Sales of the cheapest cigarettes fell 5.5 percent over the period, the WHO added, signaling that the tax prompted poor smokers, in particular, to cut back on cigarette purchases.

“This is good news, because it is people in the lowest socio-economic groups in China who are most profoundly affected by the health and economic burdens caused by smoking,” said Bernhard Schwartländer, the WHO representative in China.

Last year, China hiked its wholesale tax rate on cigarettes to 11 percent from 5 percent, an increase the WHO said earned revenue of about 70 billion yuan ($11 billion) for the central government in 2015.

Retail cigarette prices rose about 10 percent on average, with the cheapest brands becoming as much as a fifth more costly, a WHO analysis found.

Anti-smoking campaigners in China have faced tough opposition from the state-owned tobacco monopoly, which wields great sway because it contributes an estimated 7 percent to 10 percent of government tax revenue.

Two-thirds of young men in China take to smoking, mostly before the age of 20, and around half of them are eventually killed by the habit unless they quit, a study showed last year.

Governments urged to hold tobacco companies accountable

The Vision for Alternative Development (VALD), a non-governmental organisation, has joined advocates from Africa, the United Kingdom and Latin America to call on governments to hold the British American Tobacco (BAT) accountable.

The advocates claim that the BAT had made profit from generations of addiction to tobacco around the world and, therefore, their governments should demand accountability from the tobacco industry.

The call comes as BAT convenes its annual general meeting in London.

Mr Labram Musah, the Programmes Director of VALD, in a statement copied to the Ghana News Agency, said at least it was undoubtedly clear that delays in adopting Tobacco Control laws was largely due to industry interference in public health policies.

The VALD called on Ghana Government and the world over to stand firm and resolute in the midst of tobacco industry interference and formulate lifesaving legislation that would protect present and future generations from the devastating effects of tobacco use and tobacco smoke.

“While BAT’s executives toast to deadly profits and generations of addiction, people and governments around the world are organising to hold them accountable for their abuses,” Mr John Stewart, the Deputy Director at the Corporate Accountability International, has said.

Tanzania: Tobacco Company Spends Sh103 Million On Education Projects

Tabora — The Japan Tobacco International (JTI) Leaf Tanzania has spent Sh103 million on refurbishing eight classrooms and building two teachers’ houses at Migungumalo School in Uyui District.

The JTI senior vice president for Global Leaf, Mr Paul Neumann, said at the handover ceremony at the weekend that the refurbishment of the classrooms and the construction of the teachers’ houses were part of the company’s programmes on supporting tobacco farmers and their communities to address the local needs of the communities in which the firm operates.

This is aimed at establishing long-term relationships by improving the quality of life.

Apart from education, the company also helps tobacco-growing communities with water whereby in 2015 it invested in drilling of boreholes — some as deep as 140 metres – to ensure that it provides access to clean and guaranteed supply of water throughout the year.

Tabora regional commissioner Aggrey Mwanri applauded the company for the support.

How India’s cigarette makers got their butts kicked for resisting graphic warnings on packets

A heads-up for smokers in India: your cigarette packet will soon be wrapped in a bigger, more graphic, health warning, especially if you are partial to those made by ITC.

After a month of back and forth, India’s largest cigarette maker has fallen in line with a health ministry notification that requires 85% of cigarette packets to be covered with pictorial health warnings. The Indian government is pushing for tighter regulations on sale of tobacco products, which cause over a million deaths in the country every year.

Although notified in October 2014, the new rules were to be implemented by April 2016. But cigarette makers kicked up a storm and halted production for over a month, arguing that complying with these rules was simply too difficult.

On April 2, for instance, ITC announced a temporary closure of its five plants. “The implementation of any change in the health warnings on the cigarette packages is an elaborate process for the manufacturers, entailing months of preparation involving substantial cost and effort,” the Kolkata-based company said in a statement (pdf).

A fortnight later, it briefly commenced operations on April 15, even as the Karnataka Beedi Industry Association—an industry body representing local beedi workers in the state—went to the Karnataka high court seeking a stay order on implementing the new rules.

The association argued that the new rules would adversely impact India’s tobacco industry, already struggling with growing taxation burden and an increasingly long list of regulations. Sale of tobacco products generates about Rs28,000 crore in excise duty and state taxes every year, according to the Tobacco Institute of India (TII), a lobbying body for cigarette makers.

Even as it awaited the Karnataka high court’s decision, ITC pulled down the shutters again on May 4.

However, the same day, India’s supreme court took a hard stand, directing all cigarette companies to follow the new rules on pictorial warnings as move “necessary to educate people.” “You have a duty towards the society,” a two-judge bench told industry members during a hearing.

Knuckles sharply rapped, on May 08, ITC announced that it will commence operations and print new graphical warnings packets. “ITC factories have resumed production in a phased manner with the specified 85% graphical warning pending a hearing by the Karnataka high court,” a company spokesperson said.

Other cigarette makers such as Godfrey Philips and VST Industries also temporarily halted production of tobacco products to oppose the government’s decision. But with the biggest player in India’s cigarette market now towing the line, the rest are likely to swiftly follow.

Canberra diplomats in black market alcohol and tobacco probe

Foreign diplomats based in Canberra are being investigated for their alleged involvement in the black market trade of alcohol and tobacco.

The Australian Border Force has confirmed it is investigating the alleged rorting of the special privileges that allow diplomats and foreign embassies to import duty free large quantities of alcohol and cigarettes.

Twice a year, eligible diplomats are able to import 500 litres of beer, 120 litres of spirits and 10,000 cigarettes for their personal use. Embassies and high commissions can import double those amounts for official use every six months.

It is illegal for embassies or diplomats to on-sell the alcohol and cigarettes without paying taxes to the Australian government.

Fairfax Media understands the Royal Embassy of Cambodia and the Unique International Duty Free store in Clayton in Melbourne’s outer south-east are two of the main targets of a six-month-long ABF probe.

It is suspected that large quantities of alcohol and tobacco ordered by embassy officials through Unique International were never delivered to the Canberra embassy or its staff.

Instead, the products remained at the store and were sold at retail prices in an alleged rort that is estimated to have netted up to $200,000.

Online video sharing site YouTube features long promotional documentaries on the Unique International store and its range of imported beverages, which have been produced by the local arm of the Cambodian Broadcasting Network.

Unique International owner Seng Taing told Fairfax Media he could not comment on the ABF investigation.

“You need to talk to the government in Canberra,” Mr Taing said.

A spokeswoman for the ABF said she could not discuss “ongoing investigations” but warned that diplomats found to be abusing their special entitlements could face “sanctions”.

The Department of Foreign Affairs and Trade said it “is aware of allegations concerning some foreign embassies in Canberra regarding the inappropriate use of alcohol and tobacco diplomatic concessions”.

The Cambodian embassy did not respond to questions.

Fairfax Media understands that diplomats from the embassies of at least two other Asian countries are suspected of also being involved in the black market trade of alcohol and tobacco bought using duty free privileges.

It is just not foreign embassies and their staff using entitlements to import generous quantities of alcohol and tobacco – the Canberra office of the United Nations High Commissioner for Refugees has also recently been placing large orders.

While there is no suggestion the UNHCR’s imports have been sold on the black market, the refugee advocate would not discuss why it had been importing large amounts alcohol through a Canberra duty free supplier.

The UNHCR’s regional representative, Thomas Albrecht, does not have an entitlement for personal use. But the office of the UNHCR is able to import the same amount of duty free products as foreign embassies.

Mr Albrecht declined to respond to questions about the frequency and purpose of the UNHCR’s orders or discuss how they were being paid for.

Fairfax Media last month revealed how the Azerbaijan embassy had lodged official forms to import the maximum amount of alcohol and tobacco.

The ABF assessed allegations about the Azerbaijan embassy’s import requests and decided not to take action.

The embassy stated that just because it received approval to import maximum quantities it had not always ordered such big amounts.

Smoking Behavior and Healthcare Expenditure in the United States, 1992– 2009

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E-cigarette exposure in children rises 1400% in pediatrics study, vaping industry feels the FDA heat

E-cigarette exposure in children rises 1400 percent in pediatrics study, even as vaping industry feels the heat from the FDA. There has been a long-running debate on whether vaping and the use of e-cigarettes is a safer alternative to traditional tobacco cigarettes. Unfortunately, the answer is yet to be known, as e-cigarettes are still a new phenomenon and research is lagging behind the instant craze of vaping. Between 2011 and 2012, the number of teens and tweens using these products has doubled, so there has been a strong push to obtain as much information as possible regarding this style of smoking.

E-cigarettes mimic traditional cigarettes as their end glows on the inhale and a cloud of smoke follows on the exhale. Inside an e-cigarette, there is a battery, a heating element, and a cartridge that holds nicotine and other liquids and flavorings.

If nicotine is used, then e-cigarettes are still addicting, and quitting e-cigarettes with nicotine can yield similar withdrawal symptoms. Some evidence supports the argument that e-cigarettes may be safer than traditional cigarettes, but other research shows they pose a risk, especially in those with heart problems. Although research suggests that e-cigarettes are less harmful than traditional cigarettes, they carry their own risk.

E-cigarettes raise the risk of nicotine poisoning in children

There is a raised risk of nicotine poisoning in children associated with e-cigarettes, according to a new study. Researcher Alisha Kamboj wrote, “The frequency of exposures to e-cigarettes and nicotine liquid among young children reported to US [Poison Control Centers] is rising rapidly. Children exposed to e-cigarette devices and nicotine liquid are 2.5 times more likely to have a severe outcome than children exposed to cigarettes, and lethal exposure has occurred.”

The researchers examined the data from the National Poison Data System (NPDS) on single exposures involving nicotine and tobacco products from January 2012 through April 2015 among children under the age of six.

During that time period, the NPDS received 29,141 calls related to exposure. E-cigarette exposure accounted for 14.2 percent of these exposures, cigarettes accounted for 60.1 percent, and other tobacco products accounted for 16.4 percent.

The researchers noted that exposure to e-cigarettes had increased by 1492.9 percent during the study period, while exposure to traditional tobacco remained the same.

Common routes of exposure as noted by the authors were ingestion, dermal, and inhalation/nasal. Children in particular may be specifically vulnerable due to their curiosity and the enticing packaging of e-cigarettes.

FDA extends regulations on all tobacco products including e-cigarettes, cigars, and hookah

The FDA has extended regulations on all tobacco products including e-cigarettes, cigars, and hookah. In the next year or so, minors will not be allowed to purchase e-cigarettes and all ingredients will have to pass FDA approval. Some vaping liquids, although they don’t contain typical cancer-causing ingredients seen in traditional tobacco products, still contain harmful chemicals.

Shop owners will now have to send applications to the FDA to have their product approved, which is not only timely but costly as well. Application estimates can range from several hundreds of dollars to the millions.

The new FDA guidelines include:

Registering manufacturing establishments and providing product listings to the FDA
Reporting ingredients, as well as harmful and potentially harmful constituents
Requiring premarket review and authorization of new tobacco products by the FDA
Placing health warnings on product packages and advertisements
Not selling modified risk tobacco products (including those described as light, low, or mild) unless authorized by the FDA
Not allowing products to be sold to persons under the age of 18 years (both in-person and online)
Requiring age verification by photo ID
Not allowing the selling of tobacco products in vending machines (unless in an adult-only facility)
Not allowing the distribution of free samples.

On the other hand, in the U.K., the e-cigarettes are deemed safe, because – unlike in America – teenagers in the U.K. have not jumped ship on them.

The new FDA rules will be implemented by August.


E-Cigarettes Are Safer, but Not Exactly Safe

People get hooked on cigarettes, and enjoy them for that matter, because of the nicotine buzz. The nicotine doesn’t give them cancer and lung disease, though. It’s the tar and other chemicals that do the real harm.

A robust debate is going on among public health officials over whether electronic cigarettes, or e-cigarettes, can alleviate the harms of smoking tobacco, or whether they should be treated as negatively as conventional cigarettes. In other countries, such as Britain, officials are more in favor of e-cigarettes, encouraging smokers to switch from conventional to electronic.

Last week, the Food and Drug Administration issued new rules on e-cigarettes, banning their sale to anyone under 18 and requiring that adults under the age of 26 show a photo identification to buy them.

Electronic cigarettes carry the promise of delivering the nicotine without the dangerous additives. The use of e-cigarettes by youth has increased sharply in recent years. In 2011, about 1.5 percent of high school students reported using them in the last month. In 2014, more than 12 percent of students did. That means that nearly 2.5 million American middle and high school students used them in the past month.

The problem is that nicotine is generally considered less safe for children and adolescents than for adults. Poisoning is possible. It’s thought that nicotine may interfere with brain development. Most worrisome, it’s believed that becoming addicted to nicotine in any form makes smoking more likely later in life.

E-cigarettes are perceived to be less harmful than conventional cigarettes, and they are thought to be useful aids to quitting. These perceptions, however, are not always fully grounded in evidence.

There’s enough research about e-cigarettes to have warranted a number of systematic reviews and meta-analyses. A 2014 study in the journal Circulation analyzed the data from a number of angles. For instance, researchers found that the aerosol from e-cigarettes was significantly lower in toxins than from conventional cigarettes, although toxins could be detected. Those exposed secondhand were also at much lower risk from e-cigarettes than from traditional ones, though some risk might still exist.

In other words, we shouldn’t believe that e-cigarettes result in the inhalation of “harmless water vapor,” but we can accept that they are most likely much safer than conventional cigarettes.

Another review published later that year came to somewhat similar conclusions, and noted that at least a third of the scientific articles on the topic had authors with conflicts of interest. It also reported that studies found worrisome compounds in the aerosol, especially in the flavorings and propylene glycol, which is often added as a humidifying agent. The authors concluded that e-cigarettes can’t be deemed safe, though they are less harmful than conventional cigarettes. I conducted my own mini-review a couple of years ago and came to the same conclusion.

But public health officials believe that conventional cigarettes are one of the most significant public health threats, and electronic cigarettes don’t appear to be in the same league.

Many of them have argued that e-cigarettes can help people to quit smoking cigarettes, much as nicotine patches or gum do. A 2015 study in PLoS One reviewed the evidence. Among 1,242 smokers of e-cigarettes, 18 percent reported quitting conventional cigarettes for at least six months, which was significantly better than those using placebos without nicotine in them. E-cigarette use was also associated with a reduction in the number of cigarettes smoked per day. Only two studies were randomized controlled trials, however, and they were of mixed quality.

Most important, these studies could not compare the usefulness of e-cigarettes for quitting against other measures, like medications or nicotine replacement therapy. It’s possible that those are more powerful.

But others argue that e-cigarettes may be a gateway to conventional cigarette use. A meta-analysis from early this year examined how people use both types of cigarettes. It found that current smokers were significantly more likely to use e-cigarettes and conventional cigarettes together. This was even truer in adolescents, where the “use of e-cigarettes does not discourage, and may encourage, conventional cigarette use.”

I admit to being conflicted here. Of course, I’d rather no adolescents use either conventional or e-cigarettes. But I am somewhat swayed by the argument of e-cigarettes for harm reduction.

Years ago, pediatricians used to urge parents to quit smoking because of the health risk for their children. Then, enterprising researchers showed that if smoking parents would just agree to smoke several yards away from their infant, it could reduce hospitalization of infants in their first 18 months of life significantly. Now pediatricians still exhort parents to quit, but they also talk about smoking outside, away from babies. We don’t want to make the perfect the enemy of the good.

And, of course, most pediatricians would encourage adolescents to use condoms if they have sex rather than preach abstinence-only. We recognize gray areas when it comes to discussing harm reduction.

One question that few want to consider, however, is whether we’d rather young people smoke conventional cigarettes or e-cigarettes. Neither would be preferable. But a recent study in The Journal of Health Economics forces us to think about this dilemma.

Cigarette sales to minors have been dropping throughout the country for more than a decade. But in the states that introduced bans on sales of e-cigarettes to minors, the decrease in conventional cigarette use slowed significantly. In other words, more children still smoke conventional cigarettes in states that banned e-cigarettes than would be expected by looking at states without bans. The study author argues that banning e-cigarette sales to minors might increase teen smoking over all.

The overall goal should be to get children and adolescents to quit all types of smoking. Banning sales of e-cigarettes to minors may help achieve that goal, but it’s also possible it may backfire.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. Follow him on Twitter at @aaronecarroll.