Whack-a-Mole Vaping Policies Do Not Protect Youth, Stanford Medicine Study Shows

From the Stanford University School of Medicine

The Food and Drug Administration’s approach to controlling specific e-cigarette devices and flavors has failed to prevent teens and young adults from vaping, according to a Stanford Medicine study. Instead, young people are migrating to widely available flavored vaping products, including new products that circumvent FDA policies.

The findings, which was published online November 30, 2021 in the journal Addictive Behaviors, suggest that, rather than adopting policies that target particular device types and flavors, the FDA should implement comprehensive regulations covering all tobacco and nicotine-containing products to reduce nicotine use by young people.   

“Our goal was to understand, in a time after policies were announced, which tobacco products and flavors youth were able to access and use,” said the study’s senior author, Bonnie Halpern-Felsher, PhD, a professor of pediatrics at Stanford Medicine. “What we found was exactly what we were afraid of: Some young people were still using flavors and products that were purportedly restricted, and even more were using products that were completely uncontrolled. Unless we regulate all vaping products — and all nontobacco flavors of products, including menthol — young people will simply go to another nicotine-based product.”

The study’s lead author is Shivani Gaiha, PhD, instructor of pediatrics at Stanford Medicine.

In early 2020, the FDA prioritized enforcement against most flavored pod- and cartridge-based e-cigarettes, or vaping devices, which consist of a small plastic pod containing nicotine, flavors and other chemicals that snaps into a vaporizer powered by a rechargeable battery. This policy was intended to remove many popular fruit- and candy-flavored vaping products from the market.

Flavored disposable e-cigarettes were left untouched by FDA policies, the researchers noted. Disposable vaping devices look and operate like pod-based vapes but are not reusable or refillable. Since the policies were introduced, the industry has also skirted the restrictions by selling add-on components that users can attach to pod-based devices to get their flavor of choice.

The Stanford study found that in May 2020, more adolescents and young adults were using disposable than reusable pod-based devices. A similar trend was reflected in the National Youth Tobacco Survey, which showed a 1,000% increase in high school students’ use of disposable vapes between 2019 and 2020.

The current policy approach and lax regulation allow the vaping industry to invent new vaping devices that are not yet regulated and continue selling nicotine products to kids, said Halpern-Felsher. Youth buy these products online or in stores, where their age is often not verified.

“The FDA has had the authority since 2016 to regulate electronic cigarettes and vaping products,” she said. “They have been very slow to do so, and what they have been doing feels like a game of whack-a-mole, covering only one group of products at a time and allowing others to spring up.”

Teens favor e-cigarettes over traditional cigarettes

Young people now typically become addicted to nicotine by vaping, not smoking cigarettes, earlier research showed. Following their introduction in 2015, pod-based vapes, such as those made by Juul, became especially popular with teenagers because they were small and easy to conceal.

Although Juul claimed its product was intended for adults who wanted to quit smoking cigarettes, its marketing — via social media that featured images of young people using their products — appeared to target youth.

For the new study, the Stanford researchers conducted a broad survey of nicotine use among U.S. teens and young adults. The online survey, which participants completed between May 6 and 14, 2020, was intended to provide insight into nicotine use during a period when school-based national surveys were suspended because of the COVID-19 pandemic.

The study included 4,351 participants who were 13-24 years old. Of the participants, 2,167 were e-cigarette or vape users. They answered questions about the specific products they had used, including the products they had tried, and the products they had used in the 30 days prior to the survey. Participants were also asked about what products they were likely to use in the future, as well as which products they had heard of and perceived as popular among their peers.

Shift to disposable vaping devices

Two-thirds of participants were under 21, the minimum legal age for buying tobacco products and e-cigarettes in the U.S. Participants hailed from all states, and their demographics reflected those of the country as a whole. 

Among the e-cigarette or vape users, 78% had used pod- or cartridge-based vapes, 60% had used disposable vapes and 57% had used other e-cigarettes, such as tanks and mods. (Tanks and mods are vaping devices with large reservoirs of nicotine-infused fluid attached.) But participants’ recent use favored disposable vapes: In the 30 days prior to being surveyed, 54% had used disposables, 45% had used pod- or cartridge-based, and 40% had used other e-cigarettes. Participants identified the most popular pod-based product as Juul, and the most popular disposable vape product as Puff Bar. 

“We can see that the movement from pod-based to disposable vapes happened very soon after enforcement against flavored pods began in 2020,” Halpern-Felsher said. “That timeline makes the data very important and novel.”

Although policies concerning flavored nicotine vaping products were theoretically intended to reduce use by young people, teens and young adults were still using flavored products, including menthol flavors, which the FDA’s enforcement priorities did not touch. Some young people were also using other products untouched by the policies, including add-on flavor enhancers and products with names that could circumvent controls, such as “Lush Ice” and “OMG” (orange mango guava).

“Manufacturers can evade flavor restrictions without removing mint, menthol and fruit ingredients just by using ‘concept flavor’ names,” the researchers wrote in the study. “The findings support prioritizing enforcement against flavored disposables and add-on flavor enhancers, and regulating flavor ingredients, rather than flavor names or industry-chosen names.”

“We need the FDA to regulate the entire class of e-cigarette, nicotine and tobacco products,” said Halpern-Felsher. “We should not have tobacco products that are being marketed to young people, that are enticing young people, that have the nicotine levels these have and that have any flavor.”

The study’s other authors are Lauren Lempert, JD, MPH, law and policy analyst at Stanford and UC-San Francisco, and Karma McKelvey, PhD, who was a postdoctoral scholar at Stanford when the research was conducted. Halpern-Felsher and Gaiha are members of the Stanford Maternal and Child Health Research Institute, and Halpern-Felsher is a member of the Stanford Cancer Institute.

Halpern-Felsher is also the founder and executive director of the Tobacco Prevention Toolkit.

The research was funded by the Taube Research Faculty Scholar Endowment; the National Heart, Lung and Blood Institute (grant U54 HL147127); and the Food and Drug Administration Center for Tobacco Products.

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Erin Digitale
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