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Eliminating Flavors from E-cigarettes May Benefit Public Health More Than Taxing Them

Flavor variety is an important component in young smokers' decisions to switch to e-cigarettes, new research from Weill Cornell Medicine indicates. The investigators say their findings provide critical insight into what attracts teens to the products and may also help policymakers develop strategies to regulate e-cigarettes in a way that reduces teenage use without compromising a critical method for adults to quit or reduce cigarette smoking.

Dr. Michael Pesko

The study, published Jan. 20 in Addiction, found that young adult smokers were significantly more likely than adult smokers ages 25 and older to choose e-cigarettes when available in an array of flavors. Currently, there are no prohibitions on e-cigarette flavors, which include fruit, candy, and dessert — additives that may be especially appealing to teens. Limiting flavors, therefore, may be an effective way to prevent young smokers from becoming "vapers," while not significantly reducing the use of e-cigarettes among adult smokers trying to quit smoking, suggested lead author Dr. Michael F. Pesko.

"Flavor availability does not seem to matter for an older adult deciding whether to use an e-cigarette to try to quit," said Dr. Pesko, an assistant professor of healthcare policy and research at Weill Cornell Medicine. "Therefore, limiting flavor availability could be an effective regulation to accomplish the twin goals of reducing the appeal of e-cigarettes to teens while not discouraging adult smokers from trying to use an e-cigarette to quit."

E-cigarettes are currently lightly regulated in the United States. While 45 states prohibit minors from purchasing e-cigarettes, 4 states, plus the District of Columbia, allow children ages 18 years and younger to buy them legally, according to the Centers for Disease Control and Prevention. The researchers say their study provides important guidance on how to craft regulations acknowledging that the products are harmful but substantially less than cigarettes; recent statistics from the British government found that e-cigarettes are only 5 percent as harmful as cigarettes.

To estimate how potential regulations influence e-cigarette purchases, Dr. Pesko, Dr. Donald Kenkel, the Joan K. and Irwin M. Jacobs Professor at Cornell University, and colleagues at both institutions, surveyed a nationally representative sample of 1,200 adult smokers, asking them to make a dozen simulated purchasing decisions of cigarettes, e-cigarettes, or nicotine replacement therapy when the e-cigarette changed in terms of prices, flavors and warning labels.

As expected, higher prices affected all smokers' purchase choices: 18-24-year-olds chose e-cigarettes 34.4 percent of the time when they cost $3, but only 8 percent of the time when they cost $9. Older smokers selected $3 e-cigarettes 18.3 percent of the time but at $9 only 3.2 percent of the time. All smokers were least likely to choose the products with the severest of several warning labels. But only younger smokers based their choices on flavor selection: They were 3.7 percentage points more likely than older smokers to choose e-cigarettes when they came in a wide range of flavors.

While taxing e-cigarettes could keep them out of young adults' reach, it could also make them unaffordable for older smokers who are trying to quit, Dr. Pesko warned.

"Governments are worried about young people using e-cigarettes, but regulating them too harshly could send older smokers back to regular cigarettes," he said, noting that this may have been an argument leading to proposals to tax e-cigarette in 12 states failing. Rather than make e-cigarettes prohibitively expensive, state and local governments might first restrict them through flavor regulation. "Flavor regulations, as opposed to taxes, may maximize public health gains," he said.

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