If you use healthcare or live on Planet Earth, you want a comprehensive ban on flavored tobacco products. This will save the lives of your loved ones, decrease your healthcare costs, and make your environment healthier.
The inspiration for this post and podcast episode is that my state of Oregon is considering a state wide ban on characterizing flavoring agents for tobacco and nicotine products. This would include menthol, e-cigarettes, cigars and more. Statewide bans are naturally more effective than county level bans and also level the playing field for retailers across the state selling non-flavored nicotine products. I sincerely hope it passes, and wanted to do this post to highlight all the important issues around flavored nicotine products, review the arguments often made against these bans, and provide a summary of many of the topics I’ve covered previously in one handy location.
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. Many who started as children started by taking cigarettes from the packs of their parents. I am very worried about the continued availability of menthol cigarettes as well as all the characterizing flavors available in e-cigarettes, which are designed to attract and hook new users. I worry about kids today picking up the attractive looking fruit-flavored e-cigarette or vape that they see their parents using to try it for themselves. Our schools are full of kids under the legal purchase age of 21 who are using e-cigarettes.
But aren’t e-cigarettes safer than regular cigarettes? Can’t they help people quit?
This is really challenging. We don’t yet know the long-term effects of these devices, and they are also constantly changing. I have had posts and podcasts previously on the changes e-cigarettes make along the entire respiratory system, increasing infection risk, potentially causing airway disease and more. One of my partners was one of the first to report on interstitial lung disease from e-cigarettes, and we have all cared for patients in the hospital, ICU and clinic from severe lung scarring from e-cigarettes, a dreaded complication called interstitial lung disease. People have died of this. In January 2018, the National Academies of Science, Engineering and Medicine released a consensus report looking at over 800 studies and concluded that e-cigarettes contain and emit a number of potentially toxic substances and raised the concern for worsening of asthma disease, cough and wheeze with use. There are also concerns about inhalation of secondhand e-cigarette emissions, which contain nicotine, ultrafine particulates, including diacetyl, which is linked to serious lung disease, VOCs such as benzene, heavy metals from the coils in the e-cigarettes and more. The reality is that there are cancer causing chemicals in e-cigarettes and vapes, and they have only been around since the early 2000s. We will need more time to see what if any risk of cancer they carry, but based on the composition and other forms of lung disease, I would be surprised if they do not cause cancer, even if to a lesser degree than combustible cigarettes.
In my clinic, I often counsel patients who are working hard to quit smoking. Most regular adult smokers, especially those who are already seeing a lung doctor for a smoking-related lung disease, want to break free of the habit but are struggling to do so because tobacco companies hired scientists to maximize the addictive nature of cigarettes and marketing agencies to get children to start smoking and keep smoking. I generally recommend my patients try something safer than e-cigs to quit, starting with other therapies that can be helpful. If they choose to use an e-cigarette, I am certainly supportive because combustible cigarettes through regular use are known to kill over half their regular users. It is hard to be worse than that. I always counsel patients to avoid a flavored product. The flavoring chemicals add a whole new layer of risk to e-cigarettes and, apart from menthol, there are no combustible cigarettes that are flavored. I encourage people to make a plan to get off the e-cig as well if possible and if not, to at least avoid flavors.
It is also unclear the extent to which e-cigarettes 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. The American Lung Association has a “Quit Don’t Switch” campaign to help, and we know that using both e-cigs and combustible cigarettes exposes you to the risks of both products. This is hard, and I believe in a harm reduction approach, and if people want to use an e-cig as an alternative to combustible cigarettes or to quit, I am absolutely supportive if they think that is the best way to help them break free of nicotine or minimize its harms. More studies are being done, but the bottom line is that we do not need flavored inhaled nicotine to help quit smoking, and even if that is the case for a few individuals, the vast harms done by attracting and addicting new users outweigh that small and scientifically uncertain benefit, if it exists. Most patients in my office who smoke are struggling to break free from cigarettes. I cheer and high-five my patients who do manage to break their habit and will even throw in a “Quit Smoking Silly Dance” if they allow me. I 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.
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. Banning flavored nicotine products is sensible and will protect future generations. 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. I include many of their sources in the references for this post
Concerns regarding inhalation of flavoring agents:
I have a fun memory from a county tobacco ban hearing in my home county in which an individual pulled a pineapple and some other fruit out of a grocery bag and demanded to know why these fruit flavors were such a threat. It was a great visual, however, wasn’t much of an argument. First, I am unaware of any vape or e-cig flavoring juices that are actually derive from puree of purified organic pineapple. Most of these are synthetic chemicals designed to mimic flavors. Furthermore, our lungs don’t work like our liver. When we eat or drink something, even if it has some toxins in it, it passes through multiple systems our body has to keep us safe. The skin lining our mouth and esophagus is far more impermeable than the lungs. Our stomach is full of stomach acid that can start to break things down and then the digestive juices in our intestines get to work. Our intestines selectively let things across into our blood stream, and then all the blood goes to the liver, which has many enzymes designed to process potential toxins. Obviously, this system can be overwhelmed, as in with alcohol abuse that can scar the liver, etc, but the liver does a great and lifesaving job trying to process a great deal of the potential harmful chemicals we imbibe.
The lungs have NONE of that. When we inhale, air goes straight down our breathing tubes out to the tiny air sacs and across a single cell membrane into the bloodstream. This is why people like to inhale drugs instead of edibles- it’s like doing an IV injection. Sadly, everything else in that smoke or e-cig vapor or juice goes along with it and deposits along airways, in breathing sacs in the lungs and more. We don’t have the same ability in our lungs to process chemicals, scavenge out accumulating debris and more, which is why e-cigarettes and cigarettes can cause such concerning lung disease.
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. 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 have also been found in 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.
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. Longterm, 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.
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.
Menthol and synthetic non-flavored cooling agents numb the lungs and mask the natural coughing and anti-irritant response the lungs would normally have to inhaling toxins such as those in tobacco smoke and e-cigarette vapor. This enables users to inhale more, inhale deeper and more frequently, and inhale more of the dissolved addictive substance in the vapor, such as nicotine.
The 2017 and 2018 National Youth Tobacco Surveys revealed that among middle and high school students, menthol smoking was associated with greater smoking frequency and intention to continue smoking, compared to non-menthol smoking. Youth menthol smokers have significantly higher levels of measures of dependence, and that initiation with a menthol-flavored cigarette is associated with a higher relative risk of daily smoking.
Menthol bans have led to increased quit rates in those addicted to menthol cigarettes. Following the 2017 ban on menthol in Canada, menthol smokers were more likely to attempt to quit and to actually quit than non-menthol smokers.
What about ….
Finally, there is the “whataboutism” that always comes up whenever we are trying to focus on one lethal problem. What about fruit flavored alcohol? What about flavored vapes for marijuana? This is where a sense of scale can be helpful. First, tobacco is the leading cause of preventable death, disease and disability in the United States. It is also a habit that can be engaged in every day and at all hours of the day by most regular uses. Sadly, I know people that can smoke 3 packs of cigarettes per day. Many who use e-cigs can also be puffing throughout the day in multiple locations. We know that it often happens in the bathrooms of our schools, for example, as smoke detectors may not pick up the chemical plumes from the e-cigarettes. It is hard to smoke 3 packs of marijuana cigarettes in a day or vape large amounts of marijuana and continue to function at work or school. It is hard to be drinking large amounts of wine coolers at school or at work without people noticing. Obviously, there are cases where people do this, but I would guess these are less prevalent.
That being said, if experts and advocates are interested in crafting legislation to address those specific risks, I’m not opposed, and the evidence can be explored, it can come up for debate and more. However, it should not derail our focus on the lethal addictive potential of nicotine and the long-standing use of flavors to attract and addict new users to the products.
But how does this affect me? I don’t smoke or vape-
Sadly, the tobacco industry affects all of us. 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.An estimated 11.7% of U.S. annual healthcare spending could be attributed to adult cigarette smoking, translating to annual healthcare spending of more than $225 billion dollars based on total personal healthcare expenditures reported in 2014. More than 50% of this smoking-attributable spending was funded by Medicare or Medicaid- your tax dollars at work. I don’t mind paying taxes to ensure my fellow citizens get healthcare, but I hate to be paying more to help the tobacco industry profit while sickening and killing my fellow citizens. Around $50 billion was paid for by private insurance, your premium dollars at work if you are not on Medicare or Medicaid. And it is not necessarily getting better- the estimated healthcare spending attributable fraction increased more than 30% between 2010 and 2014. That is not even including a potential explosion in the use of e-cigarettes, which are potentially easier to hide and have unknown long term effects.
Even if you don’t use e-cigarettes or menthol cigarettes, addicting a new generation to nicotine is costly for all of us. As another concrete example of tobacco costs to business, the average smoking employee costs their private employer over $5,800 dollars per year in 2014 dollars, which if you averaged over a year with a pack per day habit, would come out to $16/pack. That’s not including the cost of someone smoking to the larger community and their family, including their increased lifetime healthcare expenditures, the loss of a loved one to a family, the cost of their child’s asthma, etc. The tobacco company should be paying at least $16 for every pack of cigarettes it sells if it wants to even start paying its “fair share” of the costs of using its product. If around 10% of the US population smokes and an employer of 1000 employees could have that drop to 6%, that employer would save over $220,000 at a minimum and $2.2 million over 10 years. That can help grow the US economy! The employer could grow the business, hire more people, provide better benefits, etc.
For each kid that picks up a flavored e-cigarette they are more likely to turn into an adult that suffers from worsening asthma, needs expensive inhalers, frequent doctor visits, missed sick days and more.
You are also affected by the tobacco industry if you live on Planet Earth. There is a massive environmental toll to tobacco. First of all, they are the most littered item on the planet, leeching over 7000 toxic chemicals into our environment. Every year, around 4.5 TRILLION cigarette butts pollute our beaches, oceans, rivers, cities, soil and parks. Not only is tobacco one of the leading causes of microplastic pollution with plastic cigarette buts clogging nature and waterways, but with a warming, drying planet, cigarettes are a risk for both house fires and wildfires, as are the lithium-ion batteries in e-cigarettes.
E-cigarettes are now disposable and are responsible for a great deal of electronic waste. Every second, around 5 disposable e-cigarettes in the US are being discarded, around 150 million devices per year. These contain lithium we actually need- enough lithium to power 6,000 electric vehicles. All this electronic waste joins the other floods of toxic e-waste, destined for incinerators or more. As long as you’re lucky, and it’s not causing an explosion in whatever trash can into which it was discarded, igniting a fire.
The WHO estimates that in addition to the more than 8 million human lives taken by the tobacco industry every year emits 84 million tons of CO2, and we lose 600 million trees, 200,000 hectares of land, and 22 billion tons of clean water. How does this happen? Most tobacco is grown in low and middle income countries, using farmland and water desperately needed for food resources for tobacco farming, including clearcutting more land for the same.
The Sierra Club actually has an entire arm dedicated to tobacco control, because it is such a threat.
Tobacco is contributing massively to global warming, deforestation and plastic and e-waste pollution. If you care about any of those things, you will want to see a comprehensive ban on flavored e-cigarettes.
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. If people want cinnamon, they can eat it. If they want a cough drop, they can unwrap one and pop it into their mouth. They don’t need to inhale it.
Nobody is trying to take away tobacco-flavored e-cigarettes for those who want to quit. The risk of flavored products in the market is too high. They need to go.
TLDR= Don't Light Things on Fire and Breathe them into your Lungs
To Do:
Contact your State Senator and Representative to ask them to pass a comprehensive flavored tobacco ban if your state doesn’t have one.
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.
Learn more about how you or a loved one can break free of the nicotine habit here.
If you are between 50 and 80 years old and currently smoke or have quit within the last 15 years, go to SavedByTheScan.org to find out about whether you should consider lung cancer screening.
Share this episode and post with friends and family and anyone whom you think might be interested.
To Learn More–
Tobacco is one of the biggest killers of my patients. I have dedicated many podcast episodes to it.
A Heartbreaking Trap– Website post here– episode with a youth pastor who worked for Campaign for Tobacco Free Kids about hx of menthol and other flavored tobacco products, particularly targeted at the Black community.
The Route Makes the Poison- Inhaling Flavors with Prof Ilona Jaspers– about difference between eating and inhaling flavoring chemicals. Post
Not Kool- Menthol and Lung Numbing with Prof Svent Jordt– about particular dangers of menthol and numbing products to the lungs, Post
Do the Vape Talk– episode for parents and teachers about talking to kids in their lives about e-cigs and vaping with expertise from American Lung Association, Post
Learn more about health effects of e-cigarettes in the podcast episode “Gambling with Your Lungs” and reading more here.
A County vs Big Tobacco- Fighting Flavors and Protecting Kids– episode about one of these county level battles from a few years ago that passed and with the current State Senator sponsoring the bill. Post here
If your state or county doesn’t have tobacco retail licensing, that is a vital step in knowing what is going on! Listen to the A Teen Talks Vaping episode to learn more.
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Teens Tackle Tobacco- Butts, E-cigs, Schools and more– with 2 members of Sierra Club youth tobacco project, post
Climate Change, Microplastics and Fires- the EcoToll of Tobacco with the Sierra Club– post here
References:
American Thoracic Society- Statements on tobacco control
https://www.thoracic.org/advocacy/tobacco-control/
ATS in Action– Tobacco & Kids
https://www.thoracic.org/advocacy/tobacco-kids.php
American Lung Association: https://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html
ATS Commentary for FDA nationwide flavor ban-
https://www.thoracic.org/advocacy/resources/07-13-18-ats-flavor-comments-submitted.pdf
Tobacco Control Policy Tool– https://tobaccopolicyeffects.org/
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Images either my photos or taken from commercial websites selling flavored e-cigarettes in addition to images stored by CounterTobacco.org and Stanford Research into the impact of Tobacco Advertising.
