On Balance: The Costs and Benefits of E-Cigarette Policy

Currently, e-cigarette supporters and opponents are passionately debating what regulations to impose on the products, if any. These debates have been playing out in legislative chambers across the United States, ranging from city halls to Congress, and in federal agencies including the Food and Drug Administration (FDA). Proponents who argue for no or little regulation maintain that e-cigarettes save lives by helping people quit smoking. Opponents, meanwhile, argue that e-cigarettes themselves are addicting teenagers to nicotine.


Both sides agree that smoking combustible cigarettes is dangerous: the Centers for Disease Control estimates that annually 480,000 individuals die from smoking, accounting for about one in every five deaths. Yet, there exists disagreement regarding the risks of e-cigarettes relative to combustible cigarettes. The two sides also disagree as to whether e-cigarettes are gateways to or exit ramps from other tobacco products. Ultimately, this debate centers around whether the benefits of e-cigarettes outweigh the costs; and the FDA’s regulatory impact analysis makes explicit use of such a cost-benefit analysis.

E-cigarettes were first imported into the United States in 2006 and quickly became popular. The rise in their use has coincided with a sharp decline in cigarette use for both teenagers and adults. From 2011 to 2019 youth current cigarette smoking declined by 63.3%, to 5.8%. In comparison, youth smoking declined by only 17.4% from 2003-2011 when e-cigarettes were not yet widely used. Over the same time period, youth current e-cigarette use rose from 1.5% in 2011 to 27.5% in 2019. E-cigarettes are not as regularly used among adults, with adult current use at 2.8% in 2017. The adult smoking rate, at 13.7% in 2018, has declined by 27.9% between 2011 to 2018—a modest decrease compared to the 63.3% decline among youth during that period.

More people use a nicotine product in 2019 than in 2011. Yet, because vaping may be much less dangerous than smoking, this transition towards e-cigarettes may ultimately improve public health. One government review by Public Health England concludes that e-cigarettes sold in England are unlikely to exceed 5% of the harm of cigarettes for non-pregnant adults. The National Academies of Sciences, Engineering, and Medicine in the United States advises that e-cigarettes are not without risk, but contain fewer toxicants than combustible cigarettes. For non-pregnant adults, the FDA states: “nicotine is what addicts and keeps people using tobacco products, but it is not what makes tobacco use so deadly.” The FDA, however, is concerned that e-cigarettes, although likely to prove far less harmful for non-pregnant adults, cause addiction and may harm health. The recent outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) has largely been attributed to THC-containing products from illegal informal sources; it does not appear to be associated with commercially-available e-cigarettes.

In 2016, the FDA deemed e-cigarettes to be tobacco products and, accordingly, began regulating them under their authority over the tobacco industry. State and municipal governments have also been actively regulating e-cigarettes. As of January 2020, in the United States e-cigarettes cannot be purchased by minors in any state; 22 states have enacted e-cigarette taxes; and 16 states have comprehensively banned the indoor use of e-cigarettes in bars, restaurants, and private worksites. In February 2020, a national ban on flavored e-cigarette cartridges (excluding menthol) came into effect. At about the same time, San Francisco implemented a ban on all e-cigarettes (which does not ban the sale of cigarettes).

The planned SBCA session details innovative research to help us cut through the noise and offer sound evidence on the benefits and costs of e-cigarettes. This information is intended to assist policymakers considering how to best regulate these products.

In the first paper, Dr. Pesko and colleagues extend their prior e-cigarette policy evaluation research by using data from the Behavioral Risk Factor Surveillance System and National Health Interview Survey from 2011 to 2018 to evaluate the effect of e-cigarette and cigarette tax rates on use of both products. They find that higher taxes on a given product type lead to a decline in its use; but such measures have the important spillover effect of increasing use of the opposite product—suggesting economic substitution. They find that a proposed national e-cigarette tax of $1.16 per milliliter of vaping liquid in the United States would raise adult daily cigarette users by approximately 1.0 percentage point, or by 2.5 million adults.

In a second paper, Dr. Wang and colleagues use data from the Health Information National Trends Survey and online Google Survey data to study the impact of the EVALI outbreak on risk perceptions. Immediately following the outbreak, the number of consumers who believe that e-cigarettes are more harmful than smoking almost tripled, increasing from 11% to 31%. Since then, this number has remained near 30%, suggesting that the EVALI outbreak and other recent developments in the e-cigarette market may have permanently changed risk perceptions.

In a third paper, W. Kip Viscusi uses new survey data from late 2019 to examine risk perceptions for e-cigarettes. There is substantial overestimation of e-cigarette risks of lung cancer and total mortality, which people view as at least 60% as risky as conventional cigarettes. Risk beliefs are somewhat higher than they were in 2014, but having seen media coverage of vaping illnesses is not influential. E-cigarette vaping decisions are influenced by perceptions of lower risk, not by nicotine risk perceptions, price, or taste.

In a fourth paper, Dr Yurekli used data from a 2019 poll of seven countries (Greece, India, Japan, Norway, South Africa, UK and US) to evaluate how smokers’ perceptions of harm reduction products influence their decision to switch to electronic cigarettes. The survey is part of ongoing surveillance supported by the Foundation for Smoke Free World (FSFW). FSFW is an independent, nonprofit organization, with the primary goal of bringing about the end of smoking in this generation. To achieve this goal, the Foundation supports research and initiatives that can reduce the deaths and diseases caused by toxic tobacco products.

**As the Conference was canceled, this presentation will be considered at a later date.

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