October 2, 2018

In the largest vaping survey, consisting of nearly 70,000 American adult vapers, researchers found that flavors play a vital role in the use of electronic cigarettes and vaping devices. Lead authors, Dr. Konstantinos Farsalinos, research fellow at the Onassis Cardiac Surgery Center in Athens, Greece, and Dr. Christopher Russell from the Centre for Substance Use Research, Scotland, U.K., conducted the study and designed the online questionnaire that was “open for participation from April 3rd to May 2nd,” 2018.

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The authors conducted the survey in response to the U.S. Food and Drug Administration’s (FDA) March 2018 Advanced Notice of Proposed Rulemaking. FDA sought public information “related to the role that flavors play in tobacco products.”  

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Of the 69,233 vapers in the study, the authors noted that “almost 95% of participants reported that they were ever smokers,” and only 5.2 percent “reported being never smokers.” The authors also found that nearly 92 percent of former smokers had used electronic cigarettes and vaping devices at the time of quitting.

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Furthermore, the authors found that many e-cigarette users cited using flavors at the point of initiation. On the other hand, only 20 percent of survey respondents reporting “using tobacco flavors,” at the point of initiation. The authors also found tobacco flavors to be “more prevalent among current [smokers] compared to former and never smokers.”

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This study provides further evidence to the role that flavors play in helping smokers quit combustible cigarettes and is consistent with earlier findings. A 2013 internet study by Dr. Farsalinos concluded that flavors in e-cigarettes “appear to contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking.” A 2015 online survey conducted by the Consumer Advocates for Smoke-Free Alternatives Association surveyed 27,343 Americans over the age of 18 on their use of vaping devices. Of the respondents, 72 percent “credit[ed] interesting flavors with helping them quit.” Of the respondents still smoking, “53% say interesting flavors are helping move them toward quitting.”

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On the role of tobacco flavors in e-cigarettes, a 2017 study noted in older adults “use of an e-cigarette flavored with something other than tobacco (69.3%) was … significantly higher than the same at initiation (44.1%).” Similar to the most recent survey of adult vapers, this indicates that older users of electronic cigarettes first used tobacco flavored e-liquids and products, and then transitioned to other flavors, which helped their cessation of combustible cigarettes. Eliminating flavors will force these individuals to vape only tobacco-flavored e-cigarettes, which would likely cause them to return to combustible cigarettes.

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The findings are significant as FDA, Congress, and state and local governments attempt to limit the use of e-cigarettes and vaping devices, also known as tobacco harm reduction (THR) products. In the addition to e-cigarettes, smokeless tobacco and snus, and heat-not-burn devices make up the vast majority of THR products that effectively deliver nicotine without the harmful constituents associated with combustible cigarettes.

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Numerous public health organizations including Public Health England, the Royal College of Physicians, American Cancer Society, the National Academies of Sciences, Engineering, and Medicine, and FDA have acknowledged the reduced harm of e-cigarettes and vaping devices.

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Evidence also suggests these products can mitigate health care costs associated with combustible cigarettes. State Budget Solutions concluded that estimated Medicaid savings could have amounted to $48 billion in 2012 if e-cigarettes had been substituted by current Medicaid smokers. In 2017, the R Street Institute analyzed “1% of smokers [within] demographic groups permanently switching.” Applying the analysis to Medicaid recipients, the author estimated savings “will be approximately $2.8 billion per 1 percent of [Medicaid] enrollees” over the next 25 years.

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In addition to FDA, Congress is proposing legislation that would restrict flavors in e-cigarettes. Some localities have enforced or are in the process of imposing bans on flavors in tobacco products—including e-cigarettes and menthol in combustible cigarettes.

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It’s important that policymakers refrain from imposing restrictive regulations on flavors. Ample research indicates that flavors play a vital role in helping adults transition from harmful tobacco cigarettes to THR products.

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Rather than limit the options for adults, lawmakers and regulators should promote the use of these products as they have been effective cessation devices for millions of smokers and could aid alleviating health care costs related to smoking.

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Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute or Tobacco Harm Reduction 101.