A new study published in January 2020 in the journal JAMA Network Open shows that government regulations restricting the use of e-cigarettes may be instrumental in reducing the use of these devices by American adults.
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E-cigarettes and public health concerns
Electronic cigarettes (e-cigarettes) are thought by many people to be helpful in quitting tobacco smoking and to be less dangerous than conventional cigarettes. Their use has zoomed over the past decade or so into the millions, contrary to the general trend of smoking fewer cigarettes. It is estimated that over 3% of adults in America are on e-cigarettes, but almost 8% of people aged 18-24 years.
The absence of validated safety data as well as evidence that vaping actually helps quit cigarettes is, however, a serious and ongoing concern. Some evidence suggests that vaping leads to or supplements conventional cigarettes in youngsters and young adults. Thirdly, nicotine levels are lower in e-cigarettes than in ordinary cigarettes, but the former typically contains multiple other potential toxins including heavy metals, propylene glycol, carcinogens and volatile organic chemicals, as well as thousands of flavoring agents whose actions in inhaled form are totally unknown.
Recent research shows that e-cigarettes cause damage to the vascular endothelium, oxidative stress, poor vascular function, higher cardiovascular risk and in general, poorer health.
In response partly to the recent outbreak of vaping-related, often fatal, illness in America, the manufacture, distribution and marketing of e-cigarettes has come under regulation, both by the US Food and Drug Administration (FDA) and independently by local governments. Such laws include prohibiting the sales of e-cigarettes among other tobacco products to people below the age of 21 years, prohibiting self-service displays of e-cigarettes, and their use indoors within private workplaces, bars and restaurants.
The question is, do these laws bring down the use of e-cigarettes?
The researchers used data collected via the world’s largest continuous health survey, and the best telephonic health survey in the USA – the Behavioral Risk Factor Surveillance System (BRFSS. It covers the whole country, asking about health-risk behavior, chronic illnesses and preventive health activity. The data used in the current study comes from the BRFSS 2016 and 2017 data, because these are the first years in which the use of e-cigarettes was included in the survey.
The study included over 890,000 adults, with roughly equal numbers of men and women, about 63% non-Hispanic whites. Blacks and Hispanics made up about 16% and 11% respectively.
The survey asked about current use of e-cigarettes. If the participants lived in a location where there were laws on e-cigarette use from the beginning of the survey year, they were classified as being exposed to the state law. The states were classified depending on the types of law they enacted.
About 4.5% were currently on e-cigarettes, of whom 60% were male non-Hispanic whites. Users were significantly more likely to be smokers and drinkers.
The state law most likely to be enacted was that prohibiting self-service e-cigarette displays, and then that which made it mandatory for retailers to sell e-cigarettes, or banning e-cigarettes and conventional cigarettes in bars, restaurants and private workplaces. A minimum age of 21 years was enacted only in 3 states, and only 7 had an excise tax on e-cigarettes.
How effective are laws in curbing the use of e-cigarettes? With respect to prohibition of e-cigarettes in indoor areas as described above, the odds of e-cigarette use were 10% less, as were the odds when a retail license was needed.
When there was a law against the sale of tobacco products and e-cigarettes to people below 21 years, and if there were taxes on e-cigarettes, the odds of current use were reduced by 14% and 11%, respectively. When examined by age, the odds are lower for adults below the age of 24 years, 32% less for those between 45 and 64 years, and 18% less for those above 65 years.
Rules against self-service displays were positively linked, however, with the use of e-cigarettes, with the odds being 4% higher in this case. These results are not statistically significant.
Anti-smoking laws were effective in helping smokers to quit and reducing the overall rate of smoking in America. It is therefore useful to know that similar government action against the use of e-cigarettes does help to bring down the prevalence of their use. If an area has strong regulations for retail vendor licensing, it is observed that the use of tobacco and e-cigarettes among youngsters there is generally significantly less. Unfortunately, less than a third of US states have this requirement.
The use of e-cigarettes accompanies conventional smoking in over half of cases, so that their role in helping smokers quit is far from proven. Their safety is also unproven, and they may serve as a gateway for conventional cigarettes. There is therefore much to be learned about the possible public health consequences of their use. Meanwhile, state regulations may help to prevent the emergence of new users and to reduce their use among current users as well.
Yang Du, Buyun Liu, Guifeng Xu et al. Association of electronic cigarette regulations with electronic cigarette useamong adults in the United States. JAMA Network Open 2020;3(1):e1920255. doi:10.1001/jamanetworkopen.2019.20255.