Researchers: Flavored e-cig ban could derail smoking cessation efforts

Beth LeBlanc
The Detroit News

As stores clear stock in preparation for Michigan’s flavored vaping ban, researchers and advocates have raised concerns about what the state’s prohibition will mean for those who resorted to vaping as an alternative to combustible cigarettes.

Gov. Gretchen Whitmer ordered state agencies last week to develop emergency rules that would ban the sale of flavored e-cigarette products in an attempt to curb youth vaping, which the state last month declared a public health crisis. The Trump administration is similarly moving to issue rules that would take all non-tobacco-flavored vaping products off store shelves.

E-cigarette liquid products sits on a display shelf, marked down 30%, inside the Corktown Smoke Shop.

“I'm glad this administration is doing the right thing and following Michigan’s lead to ban flavored vaping products," Whitmer said in a Wednesday statement.

But some researchers who have studied the success rates of smokers who turn to vaping as a healthier alternative called the Whitmer and Trump administration's decisions potentially "damaging for public health," especially among populations trying to ditch smoking.

"Although most smokers start with tobacco flavored e-liquid, they often switch to other flavors, most frequently to fruit and sweet flavors. In our trials, successful quitters used most frequently fruit flavors," said Peter Hajek, a Queen Mary University of London researcher who led a recent study on vaping's role in smoking cessation.

Hajek called the Trump administration's move "a really bad idea."

While vaping is “substantially less dangerous” than smoking, public health officials and policies like the emerging Michigan and federal bans have created a “distorted impression” of vaping, said Kenneth Warner, professor emeritus and dean emeritus at University of Michigan’s School of Public Health. Any increase in youth vaping is a valid concern, but the flavor ban appears to be a “very harsh measure” to curb that use, he said.

“With all the negative talk about the dangers of vaping and the like and now the policies that are going to make flavors a lot less accessible, it’s going to encourage a lot of them to quit vaping and return to cigarettes,” Warner said.

But health associations that supported Whitmer’s aggressive ban dismissed the concerns about the effect on smoking cessation efforts, calling the dilemma a “false choice” between two harmful habits.

“The FDA has not found any e-cigarette to be safe and effective in helping cigarette smokers to quit,” said Ken Fletcher, director of advocacy for the American Lung Association in Michigan.

At the Corktown Smoke Shop, owner Nathan Esquivel is putting a 30% discount on all of his flavored juices to try to clear his shelves in the next month. He said he’s trying to brainstorm ways to stay open without his most popular flavors like custard, blueberry cake and other dessert-themed options.

Flavored and colorfully packaged e-cigarette liquid products are displayed inside the Corktown Smoke Shop in Detroit. The owner of the shop has marked down all of their e-juices by 30% to try to clear out stock in the next 30 days before Gov. Gretchen Whitmer's ban takes effect.

At least one medical marijuana shop seems to be making the most of the ban, offering marijuana-derived vaping options as an alternative, even as state and federal health officials study the potential link between vapor-linked illnesses and THC vapes.

The debate arises as the Centers for Disease Control and Prevention said Friday there are 450 possible cases of lung illness, five of which were fatal, associated with the use of e-cigarette products nationwide. 

In the past, the CDC and U.S. Food and Drug Administration have warned against the use of e-cigarettes for youth and pregnant women but have acknowledged they could help adult smokers to quit regular cigarettes and may be less harmful than traditional cigarettes. 

But the FDA issued Monday a warning letter to e-cigarette manufacturer JUUL Labs Inc. for marketing itself as a “less risky” tobacco product without appropriate FDA backing. 

Now the FDA will soon issue guidance on how to take flavored vaping products off of the market, Health and Human Services Secretary Alex Azar told reporters Wednesday at the White House. The process could take months, but Azar indicated the rules still might make it possible for vaping products to gain FDA approval.

“People are dying through vaping, so we’re looking at it very closely," Trump told reporters as he noted wife Melania's concern and described e-cigarettes as a "new problem in the country."

Pot involved in vaping concerns

The CDC said Friday it had not determined a specific substance or e-cigarette product related to the 450 possible cases of lung illnesses, but said many individuals involved have also reported using e-cigarettes containing cannabis-derived products such as THC or CBD. 

The state also raised concerns about illnesses believed to be vaping-related.

Two days before the Michigan Department of Health and Human Services declared a public health emergency, the agency said it was reviewing six cases of respiratory illnesses among individuals aged 19 years old to 39 years old believed to be linked to vaping. The state said some individuals who reported illnesses believed to be vaping-related also reported use of THC-containing vape devices.

Marijuana Regulatory Agency Director Andrew Brisbo is monitoring the issues and evaluating what action, if any, is necessary by the agency, spokesman David Harns said.

Despite concerns about THC-linked vaping, at least one Michigan business was quick to offer marijuana-derived vapes as alternatives.

The Greenhouse Provisioning Center in Walled Lake said Monday medical marijuana patients could trade in their old vape cartridges and receive a CBD or state-tested THC vaping device for free. The offer came about through a partnership with Platinum Vape.

“This is a great way to give back and introduce users to an alternative,” said Cody Sadler, owner and CEO of Platinum Vape. 

The state health department said it does not support the initiative and, like the CDC, is cautioning against any use of vaping products, a spokesman said.

In the state’s finding of emergency in late August, Chief Medical Executive Joneigh Khaldun noted federal and state statistics showing marked increases in youth vaping. The state’s Profile for Healthy Youth Survey reported between 30% and 118% increases in e-cigarette use among high school students in counties across Michigan between 2015-2016 and 2017-2018.

The state attributed the increased usage to the appeal of flavored vapor and recommended the development of emergency rules to curb availability and usage.

“Use of tobacco products by all ages is a concern to the department” and the state offers an array programs and products to help people quit, Health and Human Services spokeswoman Lynn Sutfin said. But “the bottom line is the ban is intended to protect the health and safety of our youth.”

Several health groups, including the American Lung Association, applauded Whitmer’s decision and called on federal regulators to take a similarly tough approach to rampant use of vaping products.

Flavoring’s only purpose, the Lung Association's Fletcher argued, is to attract young people and get them addicted.

“We need Washington now to step up and look at these at a federal level,” Fletcher said. “We don’t want to do this state-by-state.”

‘Substantially less dangerous’

The competing interests of smoking cessation and youth usage as well as differing interpretations of research have created a storm of confusion around vaping, UM's Warner said.

“This issue has split the public health community unlike anything I’ve seen in my more than 40 years working in the field,” he said.

A study published in the New England Journal of Medicine in February tested the effectiveness of e-cigarettes among people attending a United Kingdom smoking cessation clinic by randomly assigning a group of 886 participants to e-cigarettes or other nicotine-replacement products as tools to quit.

Roughly 18% of the e-cigarette group had maintained their abstinence from cigarettes a year later compared with 9.9% of the nicotine-replacement group. Among those who abstained from cigarettes for a year, 80% continued to use e-cigarettes after a year compared with 9% of the nicotine replacement group who continued to use those alternative replacements.

The risks of continued vaping, while concerning to some, are about 5% of the risks of smoking cigarettes, said Hajek, the London-based researcher who helped lead the study. The relatively smaller risk should be balanced against the possibility that continued vaping could prevent a smoking relapse, he said.

In addition, many reports ignore statistics showing a decrease in youth smoking that appears to align with the popularity of e-cigarettes, he said.

“What is rarely reported in the U.S. is that youth who used to smoke are switching to vaping,” Hajek said. “Regular smoking (weekly or daily) among adolescents is at all-time low levels in both our countries and may well virtually disappear, unless the nicotine-seeking youth are prevented or frightened away from accessing the safer alternatives and return to smoking.”

Public health polices around vaping should strike a “balance between maximizing the benefit to adults and minimizing the risk to youth,” said Christopher Russell, a researcher at the Centre for Substance Use Research in Scotland.

“What the policy in Michigan is doing is zero of one and 100 of the other," he said.

Russell’s research into U.S. smokers noted a “tremendous success rate among smokers who tried and failed and tried and failed.” The roughly 15,000 smokers contacted for the survey were recruited during their first purchase of a JUUL starter kit. JUUL funded the study but had no say over the design, survey, analysis or reporting of the findings, Russell said. 

“Flavors are always consistently reported as a key factor in what attracted them to vaping and what helped them in the initial stages,” he said. “The key for vapers is the variability, the options of flavors, it’s like there’s a flavor for everyone.”

Shop owners in the lurch

Under Whitmer’s directive, retailers have 30 days to get rid of the banned product, a prospect that will send most of Michigan’s roughly 200 vaping shops out of business and leave ex-smokers in the lurch, according to the American Vaping Association.

The association, a group promoting e-cigarettes as a way to help smokers quit traditional cigarettes, estimates roughly 500,000 Michiganians use vaping products and a large chunk of that population is made up of former smokers, said American Vaping Association President Greg Conley.

“Undoubtedly, it’s going to send some ex-smokers back to cigarettes and it will deter many existing cigarette smokers from trying e-cigarettes,” Conley said.

Nathan Esquivel, 27, owner of Corktown Smoke Shop, has marked down all of the shop's flavored e-cigarette liquids to move them out before the ban takes effect.

Metro Detroit vape shop owners agree, noting the impact of the policy will be more than just the financial impact of divesting themselves of tens of thousands of dollars of product. Their customers should be considered as well, they said.  

While some customers buying from The Vape Shop in Hazel Park take up vaping as a way to socialize, “the majority of the customers are people quitting cigarettes,” said Peter Calkins, the shop’s owner.

“Nobody vapes straight tobacco,” Calkins said. “When people quit smoking, they don’t want something that reminds them of a cigarette.”

While the Corktown Smoke Shop isn’t able to sell even menthol-flavored vapes, flavored cigarettes and cigars are able to remain on store shelves, Esquivel noted.

“The flavors appeal to all ages,” he said. “There’s 50-year-olds who come in and want something fruity or savory because they don’t want to vape something that tastes like tobacco. That’s why they stopped smoking cigarettes.”