February 27th, 2017

Are e-liquid flavours really 'hooking another generation of kids'?

Attraction to vaping? Or attraction from smoking? Or just a consumer preference?

Predictably, depressingly, the US anti-vaping lobby has mobilised against a new Cole-Bishop Bill, HR 1136 that would hold off near complete destruction of the industry by grossly disproportionate FDA deeming regulation and implement the first steps in a sensible reshaping of American tobacco policy. But look at the argument they used.

“By working on what purports to be a technical change, “ Myers said, “ it leaves on the market the candy and fruit-flavored e-cigarettes that are so popular among young people.”

“You can put any gloss on it you want, this is the tobacco industry’s effort to continue to market flavored tobacco products to hook another generation of kids.

You hear this narrative a lot: regulators protecting kids from industry predators bearing flavours as bait. But I just wonder whether the anti-vaping activists have paused to even think about flavours and teens at all. 

To evaluate the demand to regulate these flavours (by which they mean ban them) you first need a framework for thinking about the issue – and that is not simple and may yield surprises.

Here is how I would think about this…

  1. What is the issue: flavour or descriptor?
  2. What are real youth preferences?
  3. Is the strength of flavour attraction sufficient to change behaviour?
  4. What is the pathway by which a flavour can ultimately cause harm?
  5. Has the possible protective effect of e-cigarette flavours on youth been considered?
  6. What about the possible harm to adults?
  7. How should the balance of risks and benefits be weighed?
  8. Is mention of the tobacco industry just an emotive trick?
  9. Do flavour bans come with harmful consequences?

1. What is the issue: flavour or descriptor?

The first thing is some clarity about what is the object of concern. Is the issue the flavour itself or the flavour descriptor? The advocacy literature seems mostly pre-occupied with flavour descriptors – “gummy bear” and “cotton candy” are mentioned a lot. This takes us into difficult territory – what are flavour descriptors that appeal to kids?  And how would you recognise them – they could be anything with youthful cultural references.  Who decides what a qualifies as a ‘kiddie flavour’?

2. What are real youth preferences?

It appears that many activists just assume that a childlike flavour will appeal to an adolescent more than any other flavour. But why? This literalist view defies all we know of the contrarian human condition known as ‘teenager’.  It is not obvious that the type of adolescents who take up vaping would wish to reinforce a child-like image.  Would teenage vapers prefer Scorpion Venom or Cotton Candy flavour? Equally, child-like flavours or descriptors may have a retro appeal to adults and be marketed to appeal to adults. So we should ask: is there a measurable bias in youth preferences to certain types of flavour/descriptor? Are preferences random? How do they diverge from adults, if at all?  What evidence really suggests that kids are attracted to a certain flavour category and that these are the flavours that happen to sound childish?  Are young people being asked ‘no-brainer’ survey question and the results misrepresented?  A much-cited example of the reasons given for using e-cigarettes comes from Ambrose et al in JAMA, 2015 is a useful illustration:

Leading Reasons for Non-cigarette Tobacco Product Use Among Past 30-Day Tobacco Users, by Product – Population Assessment of Tobacco and Health Study Youth Respondents Aged 12-17 Years, 2013-2014

This table illustrates the danger of overinterpreting surveys of what kids say they are doing to be the reasons why they are doing it.  The subjects were presented with a yes/no choice for each of the reasons given. It is true that they answered ‘yes’ to the first question – they like the flavours. But isn’t this an obvious answer if you have already decided to vape? Given you didn’t have to choose only one answer, who would answer ‘no’ to that question: “No, I don’t use the product because they come in flavors I like“? Or, try inverting the question to show its absurdity. Who would answer yes to “I use [the product] even though they come in flavours I don’t like?” for a consumer product? Of course, if they did have that answer, we would be genuinely concerned at the loss of self-control. 

Also, note how many teens do give positive, pro-health reasons for vaping: less harmful than cigarettes (79.1%); less harmful to people around me (78.1%); help people to quit (59.5%); doesn’t bother non-tobacco users (53.9%).  Compared to a statement of the obvious about something you choose to use those results are more interesting but are largely overlooked by anti-vaping activists.

3. Is the strength of flavour attraction sufficient to change behaviour?

But identifying what is attractive is only the first stage of the reasoning. There is a difference between a consumer preference for products within a category and an attraction so strong that it can stimulate initiation in non-users.  Many flavour preferences will merely be an expression of consumer choice among those already vaping and who would vape anyway – not the primary reason for vaping.  The Saul Shiffman (et al) paper showed that these descriptors exerted a weak attraction on non-users, scoring 0.4 on a 10-point scale of interest to non-user teens.

Note that this survey showed highest teenage interest in single malt scotch flavour (though not statistically significant) – see point 2 above. The Shiffman et al paper is debated here.

So where’s the evidence that a flavour category causes young people to start vaping, or more precisely, is so significant that its absence (via a ban) would prevent young people taking up vaping in any significant numbers, given there are thousands of flavours that are not candy or fruit?   Obviously, vendors don’t go out of their way to make the products unattractive. If they tasted awful then no-one would use them – but this is not the same as saying that a particular flavour category is a tactic to attract adolescents.

4. What is the pathway by which a flavour can ultimately cause harm?

To show harm, the flavour or descriptor attraction would need to be powerful enough to cause initiation in a young person who would not otherwise vape or prevent them stopping vaping.  This vaping would have to develop into a habit that we would class as a risk behaviour, that is an entrenched daily habit, not just being a kid messing around trying to blow big fragrant clouds (much use is experimental and without nicotine*).  Vaping among young people is in itself a ‘small harm’ because of the much lower risk of vaping compared to smoking. It only becomes a ‘big harm’ if the user progresses to smoking and would not otherwise have done so.  So a gateway effect would be needed to turn this into a significant cause for concern, in which the specific causal driver is a flavour/descriptor. There is nothing that suggests this pathway is significant.

  • * Warner KE. Frequency of E-Cigarette Use and Cigarette Smoking by American Students in 2014. Am J Prev Med. 2016 Aug;51(2):179–84. [link]
  • * Miech R, Patrick ME, O’Malley PM, Johnston LD. What are kids vaping? Results from a national survey of US adolescents. Tob Control.; 2016 [link].

5. Has the possible protective effect of e-cigarette flavours on youth been considered?  

Hardly ever discussed is the much more likely protective effect that attractors to vaping would exert.  That arises if young people who would otherwise smoke take up vaping instead or use vaping to quit smoking.  If vaping displaces smoking among young people, then strong attractors to vaping would play a positive role in this group. The same applies to marketing and promotion. The converse is that banning these attractors (if they are real) may have a harmful effect. Banning things to do with vaping is not a one-way bet for better health, for either adults or adolescents, it may just mean they smoke instead. It is important that we keep coming back to what is happening with smoking:

It is important that we keep coming back to what is happening with US teen smoking – the decline in 12th-grade cigarette smoking is three times the average long-run rate prior to 2010.  If flavours really are hooking kids, then something else quite remarkable must be going on.

It is true that there has been a sharp rise in e-cigarette use among teens (used in last 30 days), BUT much of this is experimental (kids messing around a few days a month) and without nicotine.

6. What about the possible harm to adults?  

The most important at-risk population is middle-aged adult smokers who cannot or do not want to quit nicotine. For them, vaping is a potential life-saving response to the ‘big harms’ and mounting risks of decades of smoking.  If they have preferences for the flavours/descriptors that are banned or marginalised from the market (and we know these supposedly child-like flavours are widely used by adults) then there is a likely detriment to adult smoker health to consider.  One survey of adult vapers found:

The results of this survey of dedicated users indicate that flavours are marketed in order to satisfy vapers’ demand. They appear to contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking.

And here is data from the 2015 ECF Big Survey of adult forum members (not a representative sample of the public) showing that fruits are important for a quarter of the sample and only around one quarter are using the tobacco flavour.

7. How should the balance of risks and benefits be weighed? 

It isn’t straightforward – things that make vaping attractive may be attracting adolescents away from smoking and helping adult smokers quit. On the other side, there may be some attraction of non-users to vaping but this is difficult to demonstrate and, in any case, does not carry high risks. So how to weigh up the balance of detriment and benefit?

Given most youth vaping is by young people who smoke or would be likely to smoke, then it is likely that any benefits to this group (avoiding ‘big harms’) greatly outweigh detriments (incurring ‘small harms’) to the small group of young people who otherwise would never smoke but take up vaping because of a flavour/descriptor. There is the imperative not to place obstacles in the way of adults escaping serious risks by making the products less appealing to them.

8. Is mention of the tobacco industry just an emotive trick?

Integral to the campaigning rhetoric of the anti-vaping activists is to link as much as possible to Big Tobacco – the industry with the worst reputation and most baggage. One can see how that works in campaigning, but is the industry actually doing what is attributed to them?  Mike Siegel points out they are not.  See his post Lying for Money: Campaign for Tobacco-Free Kids Solicitation is Fundamentally Dishonest. Siegel shows how activist marketing and campaigning have parted company with reality by listing the flavours of the main tobacco companies operating in the US (December 2016).

  • Altria’s MarkTen e-cigarettes come in four flavors: classic (tobacco), menthol, fusion, and winter mint. Their MarkTen XL Bold e-cigarettes only come in two flavors: classic and menthol.
  • R.J. Reynolds Vapor Company’s Vuse e-cigarettes come in seven flavors: original, mint, melon, nectar, berry, chai, and crema.
  • Imperial Brands’ blu e-cigarettes come in 14 flavors: tobacco, menthol, vanilla, cherry, blueberry, peach schnapps, strawberry mint, Carolina bold, pina colada, mint chocolate, glacier mint, caramel cafe, gold leaf, and berry cobbler.
  • British American Tobacco’s Vype e-cigarettes come in 12 basic flavor types: tobacco, apple, master blend, vanilla, mint, wild berry, green snap, scarlet kick, indigo dive, dark cherry, oriental spice, and rich aniseed.

These companies, cowed by the courts and ruled by lawyers, are now the least likely to do anything that resembles marketing to teenagers, and the list above shows little sign of doing what anti-vaping activists accuse them of. So there is no basis to link the tobacco industry to this anti-vaping claim unless you define anyone in the entire vaping industry as ‘the tobacco industry’ as part a smear-by-association gambit.

9. Do flavour bans come with harmful consequences?

I am not suggesting that we research what flavours attract young smokers to vaping, and market these in schools! But if flavours are the potent attractor that critics say, it is far from obvious that this is a bad thing for either youth or adults – and bans may come with harmful consequences.  It is far from clear that flavour descriptors do actually have the pulling power or that the flavours that critics focus on are in fact what makes a difference to behaviour.

The point is that if vaping products do substitute for smoking, then things that attract people to them are good for health. The massive emotional muddle that surrounds this issue needs more clarity and more focus on the pathways by which harm would arise or, more likely, be reduced.

22 comments to Are e-liquid flavours really “hooking another generation of kids”?

  • Andrew Thompson

    > 7. How are should the balance of risks and benefits be weighed?

    Given the emphasis of this section, that title would read better as:

    > 7. How should the balance of risks and benefits be weighed?

    Note that the title occurs twice.

    > So there is no basis to link the tobacco industry to this anti-vaping claim unless you define anyone in the entire vaping industry as ‘the tobacco industry’ as part a smear-by-association gambit.

    Well, given the FDA has won the legal right to “deem” nicotine products, or apparently anything which might contain nicotine products at any point in the future, or ant part (like a battery) that might be used in the aforementioned products, to be a tobacco product, the ..legalities (if not basic logic) seem to be on their side. Because ‘Tobacco Products’ are sold by the ‘Tobacco Industry’, the deeming regulations automatically make any member of the vape industry, part of the tobacco industry.

    Diabolical, but “deemed” to be arguably truthful.

  • michael d gross

    Another point is that by deeming, the FDA requires that all e-juices must be labelled. Even those that do not contain nicotine must state: “Made from tobacco”.

    In the absence of nicotine, I find it difficult to believe that tobacco needs to be used for the manufacture in this segment of the market, a fact that has confused some users.

  • If the Cole-Bishop amendment doesn’t move in a reasonable fashion, maybe it’s time to pick out a very expensive, respectable, retail chain and picket it with “You can put any gloss on it you want, but this company is selling alcohol in flavors in a blatant attempt to hook youth on alcohol” or “NNN kids die each year in drunken-driving accidents, and this company is blatantly marketing alcohol to children.” Also pick out some bars where legislators drink — I bet there’s one for each major party near the Capitol.
    https://grrattitude.org/2016/06/04/when-someone-says-for-the-children/

    • Jim McDonald

      The only problem with that is that the same people who want to ban e-cigarette flavors would almost certainly be in favor of doing the same with flavored alcohol products. That’s likely exactly what they would do if not for the more powerful spirits lobby.

    • Karyyl wrote, “maybe it’s time to pick out a very expensive, respectable, retail chain and picket it with “You can put any gloss on it you want, but this company is selling alcohol in flavors in a blatant attempt to hook youth on alcohol” ”

      Actually, you could do that for any major chain that sells orange juice. Antismokers go bananas over micrograms, nanograms, and even femtograms of stuff in secondary smoke out there, but what about alcohol in orange juice? There’s usually about 400 *MILLI*grams of alcohol in a liter of orange juice!

      See: http://www.sweetpoison.com/articles/dr-woodrow-monte10.html

      Alcohol is a Class A Known Human Carcinogen. 400mg is roughly 1,000 times the amount of discrete Class A carcinogenic chemicals put out by an entire cigarette (about 400 to 500 micrograms.)

      And yet this sweet flavored POISON is not only available to children, there are millions of irresponsible parents who literally MAKE their children drink glassfuls of it at breakfast!!!

      – MJM, who is also wondering… if e-liquid makers are forced to put “This is a tobacco product” on a bottle containing nothing but pg and cinnamon flavoring, are they being forced by law to lie? Forced by law to engage in intentional mis-labeling and false advertising?

  • Bill Richards

    I think the flavours and descriptors have to be able to tell consumers what to expect, I am in my 50s and still like the sweet flavours like cotton candy and raspberry, I also love banana custard, I like to know what I am buying, providing the retailers are sticking to over 18s then how can liquids with these flavour profiles be encouraging children to vape. I note that in the States you have a lot of packaging that resembles chocolate and other sweet boxes. Surely that is what you need to get away from not the actual liquid flavours

  • Lou Ritter

    Once again, Clive Bates brings perspective! Another aspect of the “US anti-vaping lobby” is hypocritical: most of the very same flavors are offered in other adult products without such accusations: http://www.biteclubeats.com/flavored-vodkas-from-bacon-to-fruit-loops/ (scroll for the list), coffees: http://www.sanmarcocoffee.com/flavored-coffee.html and then there are the nicorette gums, fruity sweet wine-coolers, hard sodas and ciders, etc. I respect the concerns towards protecting youth but hypocrisy is hypocrisy.
    The FDA claiming the deeming rule helps protect youth is another – at the time the deeming rule was published (May 10, 2016), 48 states already had laws banning sales of these products to minors: http://www.ncsl.org/research/health/alternative-nicotine-products-e-cigarettes.aspx (May 5, 2016) – NCSL is the National Conference of State Legislatures

  • […] Predictably, depressingly, the US anti-vaping lobby has mobilised against a new Cole-Bishop Bill, HR 1136 that would hold off near complete destruction of the industry by grossly disproportionate F…  […]

  • stephen bills

    The fact that the fda has made the requirement for any product that can be used for vaping to be labelled as made from tobacco or this product contains nicotine including batteries,wire,cotton is not only ignorant but illegal.Between the truth in labelling and advertising.Does this mean a 15 year old girl will no longer be able to purchase tampons,pads or qtips because the cotton can be used for vaping and you have to atleast 18 to purchase said products? according to state and federal goverment nrt products are safe but yet nicotine used in vaping products are not ? Do they have some kind of magic nicotine that the vaping industry doesn’t have access to ? i think not so is the fda going to take themselves to court for making claims they cannot prove? Are they taking all the states and federal goverment to court for giving away free samples of nicotine gum,patches and lozenges ? If they cared so much about the “children” they would allow these products to continue so many other adults can switch to a safer alternative that can not only save millions of lives of smokers but also save many others including children from the second hand smoke.I know they could care less about smokers but i am sure if you did a survey there is alot more children with smoking parents than there is children who vape.My state just fined a vapor store 50k forcing them to close down for having on thier facebook page people sharing stories how vaping helped them quit smoking with the attorney general saying we need to protect the children but then said if they paid the fine and turned over all their records so they could go after everyone for unpaid taxes they could stay open.So i guess the children are not as important as the money.

  • […] Are e-liquid flavours really “hooking another generation of kids”? […]

  • Irish Lass

    America is even worse messed up than the EU, I think. Sense seems to have flown out the window, between the TPD and the “deeming” regulations. Tobacco control and Big Pharma seem to be driving shamefully ignorant politicians into making very bad laws.

    There is no evidence that kids are taking up vaping, other than as an alternative to smoking tobacco. (Source: ASH and other surveys)

    Therefore flavours are not inducing kids to take up vaping. QED.

    On the other hand, there IS evidence that flavours help adults to switch from smoking to vaping. Which is a good thing, since vaping is MUCH safer than smoking. (Source: Royal College of Physicians report)

    This should not even be the subject of debate any more. What SHOULD be studied further is the safety – or otherwise – of different flavourings when vaped.Personally, I am avoiding “creamy” flavours when I vape now.

    (Still trying to find a vaping device and e-liquid combo that my poor lungs will tolerate, so that I can get off the smokes again…..but think I may just have found one – keeping my fingers and toes all crossed!)

  • Paul Johnson

    All good points. I’ve noted them all in monthly op-ed pieces locally but with no response or engagement from the ANTZ. They simply continue on with ads like “MYTH-Youth are protected from e-cigarettes because of purchase regulations tied to age. FACT-Currently, 18% of Alaska high school students use e-cigarettes.” First of all a non sequitur and secondly, as is clear to those of us willing to dig deeper into the methodology of the surveys, a highly over rated figure. Add to that the U.S. Surgeon General coming out with a statement that “vapor (or “aerosol” as they like to say here in the U.S., because it sounds so much more ominous)even second hand vapor, contains heavy metals such as lead, microscopic particles that get deep into the lungs, causing severe lung disease and diacetyl also linked to severe lung disease.”

    All of this is “smoke and mirrors” though. As we all know, it’s about the money. Protecting positions, salaries, market share, tax (master settlement)dollars and the status quo. Not only are most state’s budget dependent on master settlement dollars (and not for cessation programs) but the federal government’s mutual fund account (a portion of which is heavily invested in big tobacco)as well. On top of that, the FDA is now primarily funded by big pharma with only 2 congressional oversights in the last 15 years. That’s the real reason the U.S. wants to destroy vaping, there’s no money in it for them. The real vaping industry doesn’t owe them anything and would easily eliminate their NRT and tobacco related health care income and we can’t have that, now can we?

    Irish Lass, I hope you find what works for you. Best of luck!

  • Nate

    The save-the-children-from-flavors argument is a simple one. It goes like this:

    “In order to prevent young people transitioning from e-cigs to smoking, we should make e-cigs taste as much like cigarettes as possible.”

    It might actually be the single most inane tobacco controller argument of them all.

    • Andrew Thompson

      Agree fully. If an employee of a tobacco company(1) designed fruit loops flavored vapor in efforts to entice kids into tobacco flavored smoke, they’d be sacked for incompetence!

      1) But then, the tobacco companies themselves seem to be very conservative about the limited range of vapor flavors they offer.

  • Nate

    “Vaping among young people is in itself a ‘small harm’ because of the much lower risk of vaping compared to smoking. It only becomes a ‘big harm’ if the user progresses to smoking and would not otherwise have done so.”

    No, no, no. The harmfulness of a product has nothing to do with one’s likelihood of using a different product. This is magical thinking and it needs to stop.

    Even if it were materially and undeniably true that vaping “leads to” smoking, that would not make vapor products more or less harmful in and of themselves. And it sure as hell wouldn’t be a valid reason to ban or onerously restrict access to a product that is effectively harmless.

    Just as it would be disingenuous to suggest cigarettes and vapor products are not closely interrelated, it’s just as big a mistake to only view vapor products through the prism of cigarette smoking. How often have we heard vapers and vaping advocates preface their statements with “Well, no nonsmoker should ever take up vaping, but….” It is one of the most commonplace utterances is vaping activism, and it’s completely inane, because there’s absolutely no good reason why a nonsmoker (or, for that matter, a teenager) should be discouraged from taking up vaping. It is an unwitting endorsement of the most odious type of tobacco control doctrine when such statements are made.

  • Joel

    What a bullshit, I’ve started vaping because of the flavors available on the market. And I wasn’t a kid back then. The taste or the scent of the ‘real’ cigarettes is revolting for me.

  • Annette

    The only underage teenager I know who has tried vaping tried 0nic tobacco flavour. She had access to several flavours but she told me she just wanted to know what smoking was like. She mucked around with it for an evening but hasn’t persisted because “it was fun but not that exciting”.

  • […] you want to include information about why flavors matter so much to adult vapers, Clive Bates has a terrific paper describing the myths and facts about e-liquid flavors. It’s perfect for […]

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