Flavor Bans Protect Kids & Decrease Addictions

I am an ICU and lung doctor in Oregon who cares for those whose lives have been devastated by nicotine addiction and who desperately want to kick the habit. The ones who have the hardest time started before the age of 21, hooked on flavors like menthol. As I write this, in my home state, Big Tobacco is donating heavily to repeal a rule that Washington County passed to protect the kids in their county from the dangers of flavored nicotine products.

I think many people have an initial reaction that people should be able to risk their own health if they want, and that they should be “free” to buy these products if they understand the risks. Sadly, that outlook plays right into Big Tobacco’s hands, and the history is much more complicated.

Tobacco industry documents since the 1970s have shown that these companies have known that flavoring attracts children, and addicting a developing brain to nicotine makes it much harder to quit later. Flavors are designed to addict new users to a harmful product. Substances like menthol mask the harsh effects of smoke or vape and are designed to help suppress the natural cough of a new user to allow the nicotine addiction time to catch hold. Washington County’s ban on flavored nicotine products is sensible and will protect future generations. I certainly encourage Washington County residents to vote “No” on this attempt to remove these protections. I also encourage other states and counties to take up similar bans, and would hope for an eventual federal one, as there is for combustible cigarettes. Flavored nicotine products are not safe. We should not allow the sale of products that when used as directed are such a threat to health. This is different from the flavors allowed in food- we should not be inhaling food additives into our lungs. The American Thoracic Society has reviewed an extensive degree of the evidence regarding the harms of the flavoring chemicals themselves, and you can see their conclusions in the References below. I’ll review the specific concerns about the flavoring chemicals themselves here.

Concerns regarding inhalation of flavoring agents:

Stop for a minute and think. Maybe you enjoy drinking vanilla-flavored coffee or hot chocolate with cinnamon… but would you ever inhale it? Many of these flavoring chemicals are those designed to be eaten, not inhaled, and studies show that inhaling these flavoring agents can cause death of lung cells. Long before vaping oils came along, interstitial lung diseases from inhaling a variety of chemicals has been well-described. Caring for these lung diseases is expensive, and they frequently result in permanent and debilitating lung scarring that leaves people with limited work options. Our society and employers not only pay their healthcare costs, that person becomes less able to contribute to the economy of their family and their community.

Specific chemicals, such as the benzaldehyde used in cherry or almond flavorings, can cause respiratory irritation and cough when inhaled, which may not be of significant concern with one use to most users, however it can be deadly to those with the common illnesses of asthma or COPD or other pre-existing conditions, whether inhaled directly or second-hand. A popular chemical for those who enjoy cinnamon flavors is cinnamaldehyde, which can cause effects that have been associated with the development of asthma. It can cause chronic cough, inflammation and suppress important immune cells in the lung, of particular concern in the COVID19 pandemic. Suppressing the immune system of the lungs decreases the ability of a person to fight off viral and bacterial infections, which are the most common causes of exacerbations of asthma and COPD, both of which can lead to death for individuals with those conditions. Multiple flavoring agents including cinnamaldehyde and eugenol have been shown to be potential sensitizers for allergic diseases including not only asthma but also allergic dermatitis- allergy season is already miserable enough for many Oregon children! Other flavoring agents, such as vanillin which is ubiquitous in many flavored tobacco products has led to release of inflammatory mediators from neurons, a mechanism which we know long term can lead to development of asthma. The track record of other substances that have similar effects, including inhaled tobacco, is one resulting in lifelong diseases that devastate family resources and communities.

There are almost too many examples of inhalational lung diseases to mention, but well-known in the pulmonary literature is “Popcorn Lung,” a form of bronchiolitis obliterans (a deadly and feared obstructive lung disease) that develops from occupational exposure to diacetyl and other butter flavors (eg 2,3-Pentanedione and acetoin). These buttery flavors are also contained in e-cigarettes and e-liquids, despite the industry’s own trade organization, the Flavor and Extract Manufacturers Association, officially recognizing the occupational hazard of these chemicals to be risky when inhaled. Also on this list are other chemicals identified to be risky when inhaled that can be found in e-cigarettes.

We have already seen an epidemic of vaping related deaths, and despite industry insistence to the contrary, there is little scientific basis to believe that we will not see future deaths. Long term, we will need decades to discover the consequences of a lifelong habit, but a protective public health approach demands that we not addict new users to discover how deadly these products will be.

Flavoring targets youth and new users:

From sugary cereals to sugary beverages, flavors are a key part of marketing to attract new and young users. This is not just a vaping issue, the cigar and cigarillo market is growing due to fruit and candy flavored cigars designed to appeal to kids, packaged with bright candy flavors, placed in stores where visible by youth, and priced at a low point that they can afford. The top 5 most popular cigar brands for cigar users aged 12 to 17 are those that all come in flavored varieties from strawberry chocolate to apple and cherry. We know that when flavored combustible cigarettes were banned, youth tobacco use fell. This is why nicotine companies are back with flavors to try to get the kids hooked again. The rules should be the same for all flavored nicotine products.

Legal age of 21 is not sufficiently protective of youth:

Despite a legal age of 21 for nicotine products, it is important to note that use of tobacco in youth remains pervasive, and that flavoring leads to initiation and persistence of use. A 2014 study found that 70% of current middle and high school tobacco users had used a flavored product in the last month, and those 18-24 have had an 89% increase in risk of using a flavored tobacco product compared to those age 25-34. Data from the government’s Population Assessment of Tobacco and Health study (2013-2014) discovered that > 80% of 12-17 yr old kids who have ever used tobacco started with a flavored product. Two-thirds of children reported that they used a tobacco product because it came in a flavor they liked. Our schools are full of children vaping who are less than the legal age of 21. Fortunately, when flavored cigarettes were banned in 2009, we saw youth rates of cigarette use fall. That’s why Big Tobacco is back with flavored nicotine products. These should be subject to the same ban.

But aren’t e-cigarettes safer than regular cigarettes? Can’t they help people quit?

We don’t yet know the long-term effects of these devices. It is also unclear the extent to which they help people quit vs prolong the habit by being able to use devices with less detection vs simply change to another form of inhaled nicotine. More studies are being done, but the bottom line is that nobody needs flavored nicotine to help quit smoking. Most patients in my office who smoke are struggling to break free from cigarettes. The ones who have the hardest time were addicted as children. I cheer and high-five my patients who do manage to break their habit, and always ask them what combination of factors resulted in their success. Not one has ever told me that it was because “Fruity Pebbles Vape” was finally available.

Menthol: Menthol is a particularly pernicious flavor because it is like inhaling a cough drop to help the poison go down easier. Furthermore, it has historically been targeted at black communities, and its exclusion from prior tobacco flavoring bans has had devastating consequences.

Bottom Line:

The American Thoracic Society has found that: “Flavors are an essential element of the tobacco industry’s efforts to hook people on tobacco products. No one inherently wants to use tobacco-flavored tobacco. Candy, fruit or sweetened flavors lure youth to try tobacco products, mask the harshness of tobacco products and enable naive users to consume tobacco products until they become addicted. Without characterizing agents, the lure of tobacco products would be significantly reduced – much to the benefit of public health.”

I completely agree. Don’t heat things up and inhale them into your lungs. They were not designed for it. There is no need to subsidize others to begin this habit, because please understand, when the sale of these products is allowed in a community, that community is signing up to pay for a potential lifetime of disease costs. Around 8.7% of US healthcare expenditures already go to tobacco-related diseases, and 60% of that is paid for with taxpayer funded healthcare like Medicare and Medicaid. Even if you don’t use e-cigarettes, addicting a new generation to nicotine is costly for all of us.

If kids want cinnamon, they can eat it. They don’t need to inhale it.

TLDR= Don't Heat up Flavored Oils and Breathe them into your Lungs.

To Do:

Advocate for flavor bans in your county and state. Reach out to county commissioners, candidates for office and more to express your concern about the flavored nicotine epidemic.
Post on social media and consider writing an Op-Ed about why you support a ban on flavored nicotine products.
Find out if there is a flavor ban being considered in your county or state, and do what you can to support it.
Write to your members of Congress and ask them to take action against flavored nicotine at the national level.
Learn more by listening to the podcast episode “A Heartbreaking Trap” and reading accompanying materials here.
Learn more about health effects of e-cigarettes in the podcast episode “Gambling with Your Lungs” and reading more here.
Learn more about how you or a loved one can break free of the nicotine habit here.