Evidence Is Piling up on One Side of the E-cigarette Debate
Evidence Is Piling up on One Side of the E-cigarette Debate
The sharp rise in youth vaping has provoked hysteria, but the hard numbers tell a different story
US policymakers at all levels of government have cracked down on e-cigarette use.
Yet the “gateway” hypothesis — the notion that e-cigarettes will lead to renormalization of youth smoking — has little empirical support.
Despite popular misconceptions, the preponderance of evidence points to e-cigarettes as an effective harm reduction strategy to divert vulnerable youth away from more harmful tobacco products.
Across virtually all demographics, e-cigarette use has exploded in the US over the last decade, prompting federal policymakers to impose a host of restrictions on the sale and use of e-cigarettes. Yet a growing scholarly literature indicates that by raising the cost of vaping, these well-intentioned measures make smoking cessation more difficult, especially among young people.
In 2019, Congress raised the minimum age to purchase tobacco products (including e-cigarettes) from 18 to 21. Since 2020, the FDA has banned flavored vaping cartridges, and earlier this year ordered Juul — at the time, the largest e-cigarette company in the US — to remove all its vaping products from the market. In October, the FDA brought lawsuits against six e-cigarette manufacturers seeking to halt their operations.
Many state and local governments have taken similar steps to discourage vaping, including raising e-cigarette taxes, enacting indoor vaping bans and requiring product package warnings.
Opponents of these measures contend that e-cigarettes are an effective harm reduction strategy, helping to divert people away from smoking. Cracking down on e-cigarettes may curb vaping, they acknowledge, but at the cost of foregoing an effective means to sharply reduce smoking.
On the other hand, advocates of tight restrictions on vaping often point to surging rates of e-cigarette use among youth. They speculate that youth vaping, driven by the appeal of flavored e-cigarettes, will ultimately lead to a renormalization and increase in youth cigarette smoking. This chain of events is certainly plausible and worthy of close scrutiny. It is beyond question that vaping has increased sharply among high school and even middle school students. But the notion that e-cigarettes serve as a “gateway” to smoking has little empirical support.
For the most part, both sides of the debate agree that vaping, by itself, is far preferable to smoking. In 2015, an independent panel of experts convened by Public Health England conducted a systematic review of the evidence and concluded that e-cigarettes are at least 95% less harmful than conventional cigarettes. The Royal College of Physicians agrees: “… the hazard to health arising from long-term [vapor] inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.” In a recent interview with the Associated Press, even the head of the FDA’s Center for Tobacco Products, Brian King, acknowledged that “... e-cigarettes — as a general class — have markedly less risk than a combustible cigarette product.”
But while e-cigarettes do not directly present a grave public health risk, their impact on smoking carries much higher stakes. Cigarettes kill nearly half a million Americans each year and impose gargantuan economic costs through direct medical spending and lost productivity — to say nothing of the emotional and social toll of smoking-related diseases. Vaping could be a public health disaster if it gives adolescents a taste for cigarettes. On the other hand, by giving smokers a safer alternative, vaping could turn out to be a major public health victory.
For the last few years, as the data has poured in, a growing number of studies have cast serious doubt on the “gateway” hypothesis.
Rates of youth cigarette smoking collapsed in the late 2010s and remain near all-time lows. As the graph below illustrates, the proportion of high school students using cigarettes fell from 16% to 8% from 2011 to 2018, even as e-cigarette use increased from less than 2% to 21%. A 2020 paper found that from 2011 to 2015, a time when the popularity of e-cigarettes was rapidly growing among adolescents and government regulation was limited, there was little evidence that renormalization of youth smoking was occurring in the UK. In fact, combustible tobacco use among UK youth declined over that period.
Rigorous empirical methods corroborate these simple trends. The most carefully conducted, comprehensive studies have found that youth smoking rates declined as e-cigarette use increased, and that efforts to discourage youth e-cigarette use lead to higher rates of youth smoking.
In 2018, researchers estimated that a 10% federal excise tax on e-cigarettes would reduce the number of quitters in the US by more than 250,000 per year. An analysis of retail purchase data in 2020 came to similar conclusions, finding that a $1 increase in e-cigarette taxes (per milliliter of vaping fluid, equivalent to about 100-300 puffs) boosts cigarette sales by nearly 5,000 packs per 100,000 population (equivalent to one cigarette per person).
A 2021 analysis found that while higher e-cigarette taxes reduced youth vaping, they induced large increases in youth cigarette smoking. The authors caution, “... the health costs from greater youth smoking as a result of [e-cigarette] taxes may considerably undercut or even outweigh benefits from reduced youth [e-cigarette] use.”
This year, a paper published in the journal Preventive Medicine reviewed 10 sophisticated quantitative studies and concluded:
“The general driver of [policies restricting access to vaping products] has been the idea that youth e-cigarette use will re-normalize cigarette use, leading to increased rates of cigarette smoking among underage individuals. However, we demonstrate here that this thinking is unsupported, based on econometric evidence suggesting that youth e-cigarette use appears to be replacing a culture of youth smoking. When the availability of e-cigarettes is diminished through taxation and bans, cigarette use among both teenagers and adults increases.”
These studies are not the last word: More high-quality research should be conducted to provide even better insights into how e-cigarettes are affecting young people, and how public health policies can help achieve better outcomes. But based on the best available evidence, the hysteria that has gripped much of the media and many public health institutions over the rise in youth vaping is ill-founded. Sadly, poorly designed regulations meant to curb e-cigarette use threaten to erase the substantial gains made over the last decade in reducing tobacco harm.