Just as e-cigarettes have become more popular than tobacco cigs among U.S. high school students, a new study bolsters long-standing fears of public health officials: Vaping may spur teens to try tobacco later on.
The study is only the latest hit to the $2.2 billion e-cigarette industry, which over the last decade has spawned about 8,000 vape shops across the U.S. These stores, which sell plastic and metal pens that can vaporize thousands of flavors of nicotine-laced liquids, are currently unregulated. But largely because of health concerns, the FDA promises to soon release rules that would regulate the battery-powered smokes as tobacco products, even though they don't contain any tobacco.
While vaping has become more popular, teen cigarette smoking rates have dropped precipitously, from 25% of 12th graders smoking daily in 1997 to just 7% in 2014.
Vaping's rise might sound like great news, as e-cigarettes don't expose the lungs to tobacco carcinogens. But some public health experts worry that kids will become addicted to nicotine via sweet-tasting vaping, and then later turn to smoking tobacco, which kills about 6 million people every year.
Over the last three years, e-cigarettes have faced a growing patchwork of local regulations, with 371 cities and 22 counties banning them in locations that also prohibit tobacco smoking. California's legislature, meanwhile, choked on enacting such a ban statewide earlier this month.
The proposed FDA regulations are expected to have much sharper teeth. They could treat each vaping flavor similar to a new drug, forcing manufacturers to conduct proper clinical trials — at a cost of at least $300,000 — showing they don't impact public health. Industry-funded groups such as the American Vaping Association fear these restrictions will wipe out most shops.
"What's happening is that researchers, and the rest of the world, are trying to catch up to the market," health economist Frank Chaloupka of the University of Illinois at Chicago told BuzzFeed News. "There's the potential for real benefits for current smokers. And then there is the issue of kids taking them up."
In the new study, published on Tuesday in JAMA, researchers tracked 2,530 Los Angeles high school students who didn't smoke tobacco in 9th grade. Among the 222 who had already used e-cigarettes, 25.2% ended up as cigarette, cigar, or hookah smokers by the end of 10th grade, compared to just 9.3% of the ones who hadn't used e-cigarettes first.
The study authors were cautious about the findings, saying they didn't prove that e-cigarettes directly cause later tobacco smoking in teens.
In an editorial accompanying the JAMA study, Harvard Medical School's Nancy Rigotti called the results "the strongest evidence to date that e-cigarettes might pose a health hazard by encouraging adolescents to start smoking conventional tobacco products."
Still, she also noted the study didn't distinguish between kids who puffed on a cigarette once and quit and those who went on to became regular smokers — making the data only suggestive, at best.
The new study is fueling an intense fight among public health advocates over the safety of vaping.
"Few topics in public health and medicine are as contentious as electronic cigarettes," Rigotti noted in her editorial.
The debate is largely between critics who think vaping will lead to a revival of smoking, and supporters who see the products as a promising way to help cigarette smokers quit.
E-cigarettes work by heating liquid mixtures of nicotine, flavorings (everything from chewing gum to watermelon), glycerin, and other chemicals to create an inhalable vapor. There are disposable e-cigarettes, rechargeable e-cigarettes, pen-sized and larger sizes with dozens of brand names, from the throwaway OneJoy to the over-sized Lavatube.
Critics say that vaping delivers nicotine, an addictive drug, as well as some toxins, and they point to certain studies showing that vapes don't really help people quit tobacco. With use growing among teens, they see vaping as opening a door to later tobacco use, a concern abetted by recent tobacco industry moves into e-cigarettes.
Given the risks, as one group of scientists wrote last year in the journal Circulation, "e-cigarette use should be prohibited where tobacco cigarette use is prohibited, and the products should be subject to the same marketing restrictions as tobacco cigarettes."
Supporters, on the other hand, say those concerns are overblown, and point to other studies suggesting e-cigs are at least as helpful as nicotine gum or patches in helping smokers quit. E-cigarettes lack the cancer-causing carcinogens of tobacco, they argue, and have many times fewer toxins than regular cigarettes.
A British government expert report released Wednesday adds weight to supporters' views, finding that e-cigs are 95% less harmful than tobacco cigarettes. The report's authors even recommended that doctors suggest e-cigs to smokers who want to quit.
"They are a health product," Michael Siegel of Boston University School of Public Health told BuzzFeed News.
What's more, Siegel noted some e-cigarette opponents have taken funding from pharmaceutical companies that market nicotine patches or gums, a conflict of interest acknowledged in the Circulation report.
There's money at stake on both sides. A 2014 World Health Organization report on e-cigarettes cites 18 studies that mention e-cigarettes in their titles. Of those, five had researchers funded by pharmaceutical firms with competing nicotine replacement products, and three had financial involvement with the vaping industry.
Siegel criticized manufacturers for advertising e-cigarettes as glamorous or exciting, which triggers concerns about similar efforts by tobacco manufacturers to entice young smokers to take up tobacco in past decades.
"It is a real tragedy they they are being marketed as glamorous," he said. In part the marketing strategy is inevitable, he added, because any manufacturer who makes health claims for e-cigs would face FDA censure, leaving glitz as their only sales strategy.
Overdue since June, the FDA plans to “expeditiously” release rules that would regulate e-cigarettes as tobacco products.
But nobody's holding their breath just yet. "I'm not telling my clients to expect anything before the end of the year," attorney Azim Chowdhury of the Keller and Heckman law firm in Washington D.C. told BuzzFeed News.
That's because the FDA's rules will have to undergo a costs and benefits review by the Office of Management and Budget before their final release.
"FDA's mandate is to protect Americans from tobacco-related disease and death in today's rapidly evolving marketplace," FDA's Michael Felberbaum told BuzzFeed News by email, "and ultimately, regulating additional tobacco products will have a positive impact on the health of our population."
If those rules look like draft ones proposed by the agency in April, they will kick off a two-year time limit for vape shops and vape liquid manufacturers to submit studies proving their products don't, on balance, harm public health.
"That will cost millions of dollars and require very large clinical studies," Chowdhury said. "Most of these companies will go out of business eventually."
A 2009 law gave the FDA its tobacco oversight after a decades-long fight with cigarette firms. Since nicotine is derived from tobacco, the law broadly considers e-cigarettes to be tobacco products, despite not having that ingredient. The law requires public health studies for tobacco products introduced after 2007, the agency said, a year before the first sales of U.S. e-cigarettes.
Instead of forcing vape shops to conduct these expensive reviews, one lawmaker is pushing for the rules to apply only to products released after the FDA regulations are enacted. Backed by the industry, Representative Tom Cole of Oklahoma has introduced a bill calling for a 21-month delay in applying public health requirements to e-cigs. So far, the bill has attracted 26 co-sponsors.
Representative Cole's bill currently has 26 co-sponsors, not none.