An e-cigarette by any other name is still a public health risk

• Although e-cigarettes were initially marketed as a way to help smokers quit, they pose numerous public health risks
• Vaping among teens has grown precipitously in recent years, becoming an epidemic
• Michigan is the only state without any law regulating e-cigarettes

Electronic cigarettes, or e-cigarettes, have exploded in popularity over the last decade, particularly among young adults and teens. At the start of this year, Michigan was one of only two states that did not yet expressly ban the sale of e-cigarettes to minors, and the other (Pennsylvania) has already enacted other e-cigarette regulations. Michigan has already attempted to enact legislation to prevent youth from obtaining or using e-cigarettes throughout the course of multiple legislative sessions; however, stakeholders have been unable to agree on the best way to approach the youth vaping problem. Some favor extending the definition and treatment of tobacco products to e-cigarettes, while others favor a less comprehensive ban on e-cigarette sales.

Amid this conflict, Michigan law enforcement and school officials have been left without the means to stem the tide of youth e-cigarette use. Some local governments like Washtenaw County and Canton Township have begun addressing the issue through ordinances in the absence of state action.

But is the contention over how e-cigarettes are defined simply much ado about vaping?

The first commercial e-cigarette was introduced in 2003 and quickly made its way around the globe. Because the device represented novel technology, it was largely able to sidestep regulatory oversight. The e-cigarette was initially marketed as a safe device to help smokers quit; however, concerns from public health experts quickly arose, and the U.S. Food and Drug Administration (FDA) was given regulatory authority over tobacco products and included e-cigarettes under this definition through subsequent rulemaking.

The dearth of state laws and/or oversight on the marketing, sale, or possession of e-cigarettes contributed to a rapid growth in the use of these devices among youth, however. Use of e-cigarettes among high school students in the U.S. tripled from 4.5 percent in 2013 to 13.4 percent in 2014, surpassing current use of all other tobacco products; by 2018, an estimated 1 in 5 high school and 1 in 20 middle school students (3.62 million youths) were using e-cigarettes. When considering all other forms of tobacco alongside e-cigarettes, more than 27 percent of high school students were current users of tobacco products in 2018, a proportion that exceeds adult use of tobacco products. This has led the U.S. Surgeon General, Dr. Jerome Adams, to characterize e-cigarette use among youth as an epidemic.

Bills seeking to address the problem (Senate Bills 106 and 155 and House Bill 4164) would prohibit the sale (or giving) of a vaping or alternative nicotine product to anyone under 18. Further, they would prohibit minors from possessing/using such items and require retailers to post signs indicating the age requirement for such products. Vaping and alternative nicotine devices could be displayed only in locked cases or behind counters.

The proposed bill language banning the sale of e-cigarettes in Michigan’s Youth Tobacco Act shares some similarities to the way conventional cigarettes are handled, yet many core features of the way Michigan treats conventional cigarettes would not be applied to e-cigarettes by this legislation. For instance, e-cigarettes would not be covered by Michigan’s Smoke Free Air Law. This is worth consideration, since the magnitude of risk from both firsthand and secondhand exposure to vaping emissions is still uncertain, and the amount of toxicants released may vary by device and user.

Taxation of tobacco products is another important area of consideration. Taxing a product like e-cigarettes creates a price barrier that discourages use (particularly among youth, who are typically more price-sensitive than adults). Tobacco taxes are regarded as one of the best population-level strategies to limit smoking and, by extension, reduce adverse health outcomes, though the overall impact of sin taxes on consumption is still debated. Taxes also create a source of revenue that can be directed to public health efforts, such as health education and/or tobacco cessation supports and programs.

Because e-cigarettes are still relatively new, evidence of the risks posed by them is only beginning to emerge, and long-term health effects remain uncertain and may take decades to fully discern (consider that the well-known negative health effects of combustible tobacco can take many years to emerge and that e-cigarettes have only been on the market since 2006). But while the magnitude of risk is difficult to determine, there is little doubt that vaping does pose some risks. The net effect on public health is contingent both upon rates of successful adult smoking cessation balanced against youth initiation of vaping and/or smoking, as well as the inherent harmfulness of e-cigarettes.

While current evidence indicates e-cigarettes are less harmful than combustible tobacco, they still expose the user to a variety of toxic substances, such as heavy metals; estimates vary for just how harmful this exposure might be. E-cigarettes function primarily as an electronic delivery system for nicotine, but the amount of nicotine delivered to the user may vary substantially depending on characteristics of the e-cigarette, the concentration of the nicotine solution, as well as user behavior. Nicotine is highly addictive, seems involved in the development of malignant diseases, and may be particularly harmful for people with existing health issues (e.g., heart disease). Youth are at an especially high risk and the use of nicotine by teens can have serious lasting consequences on brain development. Nicotine is also harmful to human fetuses.

One counterpoint to the harms of e-cigarettes is the potential benefit from their use as a smoking cessation aid. Yet, there is still insufficient evidence that e-cigarettes are an effective way to quit smoking and these electronic nicotine delivery systems have not been approved by the FDA as a smoking cessation treatment. Other approaches for smoking cessation—such as nicotine replacement therapy and cognitive behavioral therapy at the individual level, along with broad policy strategies at the population level—have achieved reductions in smoking without the same potentials for harm. As smoking remains the leading cause of preventable death in the U.S., it is nonetheless worth continued investigation as to whether e-cigarettes might be an effective tool to help some smokers quit, but policy should always be informed first by evidence.

E-cigarettes do not appear to create a direct, one-way path from combustible tobacco to tobacco cessation. For many e-cigarette users, vaping complements smoking rather than replacing it. Some non-smokers also take up vaping: out of the estimated 10.8 million adults who used e-cigarettes in 2016, 15 percent had never smoked. Among teens, there is substantial evidence that e-cigarette use increases the risk of taking up combustible tobacco later. Evidence also suggests that individuals who have never used marijuana may have a greater odds of initiating marijuana use after using an e-cigarette during adolescence. Around 1 in 3 high school students and 1 in 4 middle school students with an e-cigarettes reported utilizing the device to use marijuana.

There are plenty of good reasons to define e-cigarettes as tobacco—this is the most direct way to optimize public health through regulation, while also projecting to the public that these devices are not as benign as advertisers would like consumers to believe. And yet, while the adults in the legislature debate, more and more teens are taking up the habit. Since the definition of such devices is not consistent among neighboring states, many groups (from school administrators to law enforcement) have begun to worry that Michigan is making the “perfect the enemy of the good” by failing to provide any mechanisms to get these devices out of the hands of teens while debating comprehensive regulations. Many health officials contend that Michigan’s policy should aim to get things right the first time by crafting optimal long-term public health protections.

While thoughtful decision-makers may disagree about what constitutes “optimal regulation,” there should be little disagreement that Michigan is behind the times when it comes to keeping e-cigarettes out of the hands of minors. In a state where public health catastrophes seem as abundant as our supply of (ostensibly) fresh water, we should at least consider that ideological compromise is often preferable to compromising health.