Ban on flavored nicotine products is a public-health imperative

We disagree with Susan Collins’ Op-Ed describing the state ban on flavored vaping products as “politics of the moment” and “contraindicated by scientific data and history’s lessons.”

We would argue that Washington state’s ban on flavored vaping products is a stopgap public-health imperative. The ban is not backed by science but by the dearth of it.

More than 7,000 unique flavors are in the market, utilizing ingredients “generally recognized as safe” by the U.S. Food and Drug Administration (FDA) for oral consumption in food. Most of these chemicals were never studied for toxicity via the inhalation route. This unsettling fact also was recognized by the Flavor and Extract Manufacturers Association in a 2013 statement.

Scientists have been concerned about inhalation of flavored chemicals for at least five years now, but the challenges of research in this area are enormous.

In the unregulated U.S. market, flavoring composition is proprietary, protected corporate information, making it challenging to determine a risk profile specific to each flavor.

The presence of ethyl maltol in some JUUL pods flavors is high enough to damage or even kill living cells (cytotoxic) in rigorous laboratory studies. A study of mice exposed to vaping inhalation found that flavored vapors, particularly sweet or fruity ones, resulted in oxidative and inflammatory responses in lung cells and tissues. These are considered key events in the development of chronic airway diseases.

Despite these concerns, advertising by powerful corporations, including tobacco interests, has promoted flavored nicotine products as innocuous.

Adolescents are especially susceptible to advertising. Of particular concern is that youth may falsely believe that flavored vaping is a nicotine-free product. One study, using data from 2017 and 2018, compared youth self-reporting of nicotine through vaping devices with their urinary biomarkers. It found that 40% of those who reported using nicotine-free products had significant amounts of a biomarker for nicotine exposure in their urine.

This finding seems to hold true for youths who use JUUL, whose products always have nicotine and do not include a flavor-only, nicotine-free option. One study found that 63% of JUUL users ages 15-24 believed that JUUL cartridges contained no nicotine. In fact, one JUUL pod, on average, contains as much nicotine as is found in 20 cigarettes, the U.S. Surgeon General warned.

In a recent and comprehensive review of scientific evidence, The National Academies of Sciences, Engineering and Medicine concluded that there is substantial evidence that vaping use among youth and young adults increases the risk of ever using combustible tobacco cigarettes.

This finding seems to hold true across numerous age groups and even for youth who are at low risk for tobacco use, such as youth who do not have friends who smoke. For youth who report using combustible cigarettes even once, vaping may increase the frequency of combustible cigarette smoking.

We appreciate that in the United Kingdom, nicotine vaping has been successfully used as a smoking-cessation tool. One lesson to be learned from that: Clinical practices must be assessed in the context of health policies.

Nicotine vaping devices are regulated in the U.K. as medicinal products by the Medicines and Healthcare products Regulatory Agency (MHRA), whose function is equivalent to the FDA. Every chemical used on these products must be reported to MHRA.

Moreover, the U.K. strictly regulates vaping advertising and sales outside the health services system. In this context, a 2019 randomized trial of adults seeking help to quit smoking through the U.K. National Health Services found that smokers in counseling had double the chance to have successfully quit tobacco one year later if they received a nicotine vaping starter kit, when compared with those who received nicotine patches.

On this side of the pond, nicotine vaping has yet to be regulated by the FDA, is widely advertised, and is available online and in many retail stores. Washington state’s ban on flavored products is a step in the right direction because it places responsibility to demonstrate product safety on the corporations that are profiting from these products.