San Francisco city officials recently proposed new legislation that would essentially ban the sale of all e-cigarettes in the city until the Food and Drug Administration (FDA) conducts a thorough public health review allowing the products to be sold. The proposal is the first of its kind in the United States and questions both the overall safety profile of e-cigarettes, and whether vaping acts as a gateway for young people into using tobacco products.

E-cigarette prohibitions have quietly been spreading around the globe in recent years. Singapore, Thailand and Brazil, are just a few countries with complete e-cigarette bans, while many others either heavily regulate sales or disallow nicotine-based vape liquids.

Hong Kong is the latest region to propose strict regulations, recently beginning the process for a blanket ban on the sale, importation or promotion of e-cigarettes. At this stage the local government is only concerned with stemming the importation and sale of e-cigarettes, so it will remain legal to use the products – for now. In a comment to CNN, a Hong Kong official suggested the government views e-cigarettes as, "a gateway to the eventual consumption of conventional cigarettes."

San Francisco officials echo the "gateway" hypothesis, suggesting that alongside potential safety questions, the big concern with e-cigarettes is that young people are taking up the habit, and potentially ending up with a nicotine addiction that may ultimately lead to tobacco use.

"E-cigarettes have been targeting our young people with their colors and flavors that entice adolescents and predatorily pull them towards addiction to nicotine," San Francisco City Supervisor Shamann Walton said recently in a statement. "Companies like Juul are contributing to increased numbers of people addicted to nicotine – people who would have never picked up a cigarette. Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth."

Juul, kids, and making vaping cool

The name-dropping of Juul in Shamann Walton's statement is not accidental. Juul is a massive player in the vaping business, reportedly claiming over 75 percent of the total e-cigarette market in the United States. This Silicon Valley startup only launched back in 2015, yet in a few short years has cultivated a multi-billion-dollar market with its USB-shaped vape pens and sweet-flavored nicotine e-liquids.

A Stanford research team, investigating how the company marketed itself between 2015 and 2018, recently revealed Juul clearly targeted youth audiences, particularly in its first six months on the market. The striking analysis suggested Juul's aggressive youth targeting played a major role in the rapid growth of teenage e-cigarette use in the United States over the past three years.

By late 2018 one study concluded over 20 percent of US high school students used e-cigarettes. This represented an incredible 78 percent increase from the year prior. At the same time Altria, parent company of Philip Morris and one of the world's biggest tobacco conglomerates, bought a massive 35 percent share in Juul.

Spending more than US$12 billion to invest in Juul, Altria's move into the e-cigarette business raised a whole host of questions. Why would a tobacco company invest in a product many see as a cigarette alternative? Is it a way of shoring up profits as traditional cigarette smoking inevitably declines, or is this a tacit admission that e-cigarette use is a way to hook a whole new generation on nicotine?

The gateway to smoking

There are two fundamental questions that hover around any e-cigarette regulation debate. What are the health risks associated with e-cigarettes? And, does adolescent or young adult e-cigarette use increase the likelihood of the subject eventually taking up tobacco smoking?

The first question, on e-cigarette health risks, is still a big focus for scientists around the globe. It is becoming increasingly clear that while e-cigarettes may not be as harmful as combustable cigarettes, they are certainly not harmless. A variety of research is slowly revealing the uniquely damaging effects of e-cigarettes, and while they certainly may help wean current smokers off traditional cigarettes, they are certainly not a "healthy alternative."

The second question surrounding e-cigarette regulation is a much thornier one. There is a considerable growing body of evidence to suggest e-cigarette use by the young does indeed increase their risk of trying conventional cigarettes. One massive report published in 2018 was strongly divided in its conclusions over the public health effects of e-cigarettes. It found "substantial evidence" to suggest that e-cigarette use by young people increases their chances of using conventional cigarettes, but also found that e-cigarettes can also improve the health of adult smokers by offering a way to move away from combustable cigarettes.

"E-cigarettes cannot be simply categorized as either beneficial or harmful," says David Eaton, chair of the committee behind the 2018 report, summarizing the conflicted nature of the study's conclusions. "In some circumstances, such as their use by non-smoking adolescents and young adults, their adverse effects clearly warrant concern. In other cases, such as when adult smokers use them to quit smoking, they offer an opportunity to reduce smoking-related illness."

A more recent study again came to the same conclusion on e-cigarettes acting as a gateway for young people into cigarette smoking. Examining over 6,000 subjects between the ages of 12 and 15, the study found those adolescents using e-cigarettes were four times more likely to move onto cigarette smoking than non-e-cigarette users.

It's difficult to clearly conclude causality from these studies. E-cigarette advocates suggest one of the key metrics to debunk this purported association is to look at current rates of youth cigarette smoking. While teen vaping rates have dramatically surged in recent years, teenage cigarette use has consistently declined. There has to date been no notable upswing in teenage tobacco use across the past few years. In fact, the rates of teen smoking in the US have fallen from around 11 percent in 2015 to just over 7 percent in 2018.

So what can we be sure of?

We can certainly say that adolescent e-cigarette use is rapidly increasing. So much so that in 2018 the US Surgeon General declared e-cigarette use among America's youth was a national epidemic.

It is too soon to tell whether e-cigarettes are hooking a whole new generation on nicotine or whether e-cigarettes definitively cause significant long-term health damage. It's also too soon to tell whether e-cigarettes conclusively help traditional adult smokers quit or whether they just end up maintaining a person's nicotine addiction through a different, albeit potentially safer, medium.

Despite Juul's adamant claim that, "Juul is intended for adult smokers only who want to switch from combustible cigarettes," the reality is that the vape market is rapidly growing and it consists of a large volume of young non-smokers.

Currently, global approaches to e-cigarettes span the gamut from complete blanket bans (Brazil, Singapore, Thailand), to an absolute and free open market (Russia, the Netherlands, Armenia). In between those extremes there are a huge variety of different approaches. Australia and Japan, for example, allow e-cigarettes but ban the addition of nicotine to e-liquids.

This regulatory debate is certainly nowhere near a conclusion, and while e-cigarettes may be safer than tobacco cigarettes, that is undeniably a low bar to be working off. Dennis Herrera, City Attorney for San Francisco reasonably suggests the need to consider the fact that most e-cigarettes still trade in an addictive product – nicotine. Herrera notes that while e-cigarette companies may claim they are selling a safe product geared towards harm reduction, they are still addicting consumers to nicotine. And the big question that remains unanswered is whether the public health benefits of weaning adult smokers off cigarettes outweighs the harm of potentially hooking a whole new generation on nicotine.

"Like the cigarette companies, they are in the business of getting people addicted to nicotine or keeping them addicted to it," Herrera says. "That's particularly true when it comes to young people. Any purported health benefit of these devices over conventional cigarettes, even if proven at some point to be true for some smokers, is not an excuse to turn another generation of kids into addicts. Common-sense regulations to prevent youth addiction need to be in place – and should have been in place from the get go."

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