Unpacking the Unintended Consequences of E-Cigarette Policy in the Northeast
Concerns over youth use drive most e-cigarette policy decisions in northeastern states. However, these policies often negatively affect adult smokers who use them as an alternative to combustible cigarettes. Policymakers should instead focus on enforcing existing age restrictions and increasing youth-based education on nicotine use.
Common e-cigarette restrictions, such as flavor bans, high excise taxes and limits on nicotine concentration unintentionally worsen public health outcomes by increasing the relative appeal of combustible cigarettes.
A harm reduction approach that positions e-cigarettes as a smoking cessation tool has worked in the United Kingdom to bring down rates of smoking while keeping rates of youth vaping low. A similar model in the United States would work far better than our current prohibitionist approach.
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From the time they were first introduced into the market, e-cigarettes have been at the center of a public health debate about their value as smoking-cessation devices versus their appeal to adolescents and potential youth uptake. Since 2019, elected officials in the Northeastern region of the United States—defined herein as Maryland to Maine—have put more weight on the risk of the latter, enacting regulations and legislation that aim to quell youth uptake. Primarily, these states have enacted some legislative combination of restricting access to flavored liquids in e-cigarettes, capping the amount of nicotine in e-cigarette liquids and raising excise taxes on e-cigarettes.
Unfortunately, each of these strategies has the potential unintended consequence of driving former combustible cigarette users back to combustibles, which presents far greater risks than using e-cigarettes. Public health is best served when there are a variety of significantly less harmful alternatives to combustible cigarettes, and Northeast legislators should carefully consider the unintended negative health consequences of impeding the transition from combustibles to e-cigarettes.
The innovators behind the modern e-cigarette—also called “electronic nicotine delivery systems” (ENDS)—originally intended to fundamentally alter the relationship between nicotine and combustible cigarettes. They set out not to benefit the “big tobacco” industry, but to disrupt it, offering a product that delivered nicotine more cleanly and without the carcinogenic side effects of combustible tobacco products.
It took only a few short years and various innovations for e-cigarettes to begin flying off the shelves. While many landed in the hands of adult smokers, as intended, and offered a less harmful alternative to combustible cigarettes, some found their way to adolescents. Steps were rightly taken to limit both the accessibility and desirability of e-cigarettes to young people who had never used nicotine before, including raising the age of any nicotine purchase to 21 years and educating students on the addictive quality of these products. Early indicators suggest that these policies have been successful in reducing teen vaping: The percentage of teens vaping appears to have peaked in 2019 at 27.3 percent and has since declined to 11.3 percent in the most recent 2021 figures. Importantly, though, these policies are still relatively new and should be considered within the context of the COVID-19 pandemic, during which many students attended school virtually and did not have access to the environment where vaping often begins.
Still, these decreasing trends do not support the narrative of a growing vaping crisis among youth that continues to be used by elected officials to enact restrictive policies on these products at the federal, state and local levels. Although these policies are well intentioned—adolescents should not use nicotine products at all—they are blunt instruments that have little effect on youth vaping. Instead, such policies inhibit easy access to reduced-risk products for adult cigarette smokers who would benefit from transitioning to less harmful nicotine products.
State legislators in the Northeast region of the United States took particularly strong action to regulate e-cigarettes, even to the extent of removing many of these products from shelves. Their strategies to quell youth uptake of e-cigarettes resulted in three distinct approaches:
- Banning the sale of flavored e-cigarettes
- Capping the amount of nicotine in e-liquids
- Levying state excise taxes that are at parity with or higher than those levied on combustible tobacco products (e.g., cigarettes) or non-combustible tobacco products (e.g., chewing tobacco)
Unfortunately, because each of these approaches lowers the relative draw of e-cigarettes compared to combustible cigarettes for smokers, they may unintentionally result in worse health outcomes.