Let’s Actually Think about the Children, Part 2

Yes, I know. You thought my other post was linkbait. But read the post before you start slamming me in the comments.

And yes, I was going to write about flavors and marketing for Part 2 in this series, but after my conversation with Tiffany Mok in Assemblymember Dickinson’s office yesterday, and in particular after seeing the news about the proposed ordinance in Oakley this evening (the ordinance was proposed during yesterday’s city council meeting, but I saw the news this evening), I realized I had to write this post first.

Let me say first that Tiffany Mok is an absolute treasure. I phoned Dickinson’s office yesterday morning to find out when AB 1500 was scheduled to go in front of the Appropriations Committee, as it wasn’t on the schedule for the 14th. I expected to be given a date and possibly a brush-off, since there’s on reason for anyone in Assemblymember Dickinson’s office to be especially fond of e-cigarette advocates. (How did I get to be an advocate? I started out as the chauffeur.)

I ended up talking to Tiffany for 30 minutes, as she showed me how to check the Daily File and we exchanged perspectives on the proposed bill. It was a great reminder that if you have a problem with a piece of legislation, you should talk to the legislator. It’s not a guarantee that you’ll get your way, but it’s much easier to make your point in a telephone conversation than when facing a committee.

Tiffany explained that when she started working for Assemblymember Dickinson in March, she too was skeptical that teens were buying e-cigarettes online. But she started to interview teenagers and schoolteachers. In fact, she said that her friends and colleagues have taken to calling her “e-cig” because she asks everyone about them.

What she found was that every young person she asked knew about e-cigarettes and every teacher had seen them in the classroom, though it was hard to catch the kids at it “Because they look just like pens.”

“Funny,” I responded. “All the middle-aged vapers I know use mods that don’t look anything at all like pens. It must be a generational thing.” But then, the middle-aged vapers I know aren’t trying to hide the fact that they are vaping. A massive mech mod and dripper would be a bit hard to conceal in a classroom, as would the plumes of vapor.

I want to acknowledge Tiffany’s experience. I hope I haven’t given the impression in previous posts that I don’t think teenagers use e-cigarettes at all. I also don’t want to suggest that just because adults like flavors, teens wouldn’t. The ASH study I quoted in Part 1 of this series found that 7% of British teens they surveyed in 2013 had ever used an e-cigarette–a number that dropped to 1% for those who did not smoke. (By comparison, 51.7% of adult smokers surveyed in 2014 had tried e-cigarettes.) The National Youth Survey on Tobacco data for 2011 and 2012 reported 4.7% of high school students in the US had ever used an e-cigarette.

Those are small numbers, but they are not non-existent. (And they don’t count the kids who use e-cigarettes for marijuana, either.) Even with such low percentages, you could get “one in every classroom” in school of any size. A small group, but visible, as troublemakers always are. And it’s certain to be the troublemakers, you know.

Because Tiffany and Roger Dickinson and I all agree on one thing: minors should not be using e-cigarettes. They should certainly not be using them at school.

Come again? If E-cigarettes are okay for adults, why not for teens?

So far as we know, e-cigarettes are much safer than tobacco cigarettes (known as “analogs” in the vaping community). Cigarettes contain more than 4,000 chemicals, including 50 known carcinogens. There’s a massive body of research conducted over decades that demonstrates that smoking cigarettes is hazardous to your health. Forget cancer and heart disease for a minute: people die from smoke inhalation.

E-cigarettes have positive short-term effects on the health of vapers, but e-cigarettes haven’t existed long enough for anyone to conduct longitudinal studies. We simply have no information about the long-term effects of vaping. There isn’t all that much information about the effects of nicotine when you separate it from tobacco smoke, though companies like GlaxoSmithKline had to conduct tests in order to be able to produce nicotine replacement therapy products like Nicorette® Gum and Nicoderm® patches.

Other than nicotine, the ingredients of e-liquid are propylene glycol (used in asthma inhalers), vegetable glycerine, and flavorings. Of those three, the flavorings are the most likely to contain questionable ingredients, but reputable manufacturers have already had chemical profiles done on food-grade flavorings to see which ones are safest for inhalation. The vapers I know distrust e-liquid from overseas and some prefer to make their own, just to be absolutely sure they know what’s in it.

Nicotine itself is not carcinogenic, but it is addictive. (Though, anecdotally, e-cigarettes do not appear to create the same kinds of cravings that tobacco cigarettes do, which suggests that some of the addictiveness of tobacco cigarettes comes from an ingredient other than nicotine.) It has an effect on the brain, and since adolescent brains are still in the process of development, it’s better not to introduce drugs to them, in case they affect brain development.

Once they’re adults, it’s their own choice whether to engage in self-destructive behavior, as long as it doesn’t injure other people.

Most of us use at least one harmful and/or potentially addictive substance on a daily basis and don’t even think about it. Caffeine, anyone? How about chocolate, which is impressively mood-altering? Or perhaps artificial sweeteners, which are linked to all kinds of problems. And then there’s alcohol, which most people can use safely in moderation, but many cannot. (And we all know how trying to ban that worked out.) Never mind all of the possible side effects from the over-the-counter and prescription medications that adults in this country take every day.

If we really wanted children’s brains to develop safely, not only would we keep them away from tobacco and alcohol, but we would prevent them from having access to caffeine, chocolate, refined sugar, and any medication that hasn’t specifically been tested on children.

But even though rates of childhood obesity and diabetes have skyrocketed, and there has been plenty of finger-pointing in the direction of fast-food restaurants, I have not seen a serious move to institute a minimum age for the consumption of soda, candy, sugar cereal, or even coffee. (I’m not sure I’ve even seen a frivolous move, but I haven’t been paying that much attention.)

Public health would probably be vastly improved if no one under the age of 21 had access to chocolate. Imagine the reduction in hyperactivity disorders if no one fed small children sugar. Or caffeine. It’d be a bummer for the makers of Ritalin®, though.

It’s amusing to imagine the public uproar, but laws like that would never pass. There are too many powerful interests opposing them.

Teens should not use these substances, but they will. Adolescents have notoriously bad judgment. They can’t help it. The part of their brains that hasn’t finished developing is the part that understands consequences. Your teenager understands consequences about as well as your cat does. If the penalty isn’t immediate, it might as well not exist.

Most people who are going to start smoking do so when they are young. That is not just because cigarette advertising targets minors. It’s because adolescence is when you are at your most susceptible. Even smart people are stupid in their teens. If you don’t start when you’re young, smoking gets to be a lot less interesting.

So why not legislate against teen use of e-cigarettes?

Yesterday I was trying to persuade Tiffany that AB 1500 would not stop teens from obtaining or using e-cigarettes, because I have trouble believing that minors are buying online in large quantities, and in particular that they are buying online from California vendors. No one under 18 can get a credit card without the cooperation of an adult. The adult guardian has a responsibility to monitor the teen’s purchases.

I know that most people are too lazy to monitor their own credit card and bank statements, but that is not the responsibility of the law. Your bank may have a legal responsibility to notify you if there is a data breach at their end, but it is your responsibility to notify the bank if your card is lost or stolen or if you are a victim of identity theft. If the thief in question is your own child, you might forbear a police report and simply take away the card.

But this morning I woke up at Kiki-o’-clock (that’s the time at which my cat Kiki decides I need to get up, which in this case was about 4:30 a.m.) with a new realization. If AB 1500 actually prevented teens from buying e-cigarettes, that might not be a good thing.

Huh?

Think about it. If it’s too difficult for adult vapers to get e-cigarettes, they will go back to smoking. This would be a terrible thing for people who have finally been freed from the burden of tobacco.

What do you think teenage vapers would do if they couldn’t get e-cigarettes?

Well, duh. They would go back to smoking.

The key word is back. You see, Tiffany sent me links to two studies, one I had heard of but not read, and a new one. Both cite statistics for teen e-cigarette use, which though still low, is on the rise. Both express concern that teen vaping is a problem, and specifically the concern that vaping could lead teens to smoking.

This is possibly the most ridiculous–and dangerous–claim about vaping that I have ever heard.

Gateway, My Great Aunt’s Fanny.

Many years ago (it’s the 25th reunion of my graduation from Brown University this month, in fact), I took a statistics class. It wasn’t my best class, but there was one thing the professor pounded into our heads: correlation does not imply causation. The hilarious Spurious Correlations website illustrates this with graphs that map, for example, the divorce rate in Maine to US consumption of margarine.

So let’s look at these studies. The older one, co-authored by fervent e-cig opponent Stanton Glantz and published in JAMA Pediatrics on March 6, 2014, evaluates the National Youth Tobacco Survey data and concludes that because adolescents who have ever used, or currently use, e-cigarettes, are more likely to be current smokers, e-cigarettes “are unlikely to discourage conventional cigarette smoking among youth.”

This is appalling, sloppy research. Yes, it does appear that a number of teens are dual users. But there is absolutely nothing in this study that actually supports a conclusion that e-cigarette usage leads to cigarette smoking. The information in the National Youth Tobacco Survey is point-in-time data. It tells you what the people surveyed are doing (or admit to doing) at the time they are surveyed.

It does not tell you whether the teens who use both e-cigarettes and conventional cigarettes switch to e-cigarettes.It does not tell you whether those who did not smoke before and tried an e-cigarette will start smoking. That information is not contained in those numbers. The surveyors don’t know. Therefore the authors of the report cannot know.

The survey also apparently did not ask teens why they continued to smoke even after starting to use e-cigarettes. So we don’t know whether it’s because the e-cigarettes they use fail to deliver a sufficiently satisfying experience (the reason most adults remain dual-users), or because they have more difficulty obtaining e-cigarettes than regular cigarettes.

The second study, from Legacy, referencing The 2014 TRU Youth Monitor Presentation, reports that

In 2013, 41% of teens and 61% of young adults reported that e-cigarettes were “in” or “on the way in.” In contrast, the percentage of teens and young adults saying that traditional tobacco products such as cigarettes, cigars, and smokeless tobacco were “in” or “on the way in” declined from 2012 to 2013, as did the rates for alcohol and marijuana.

That information would tend to suggest that e-cigarettes are more likely to replace tobacco cigarettes than open a pathway to them.

However, while the Legacy study’s more recent survey numbers show an increase in use of e-cigarette in children aged 13-17, the percentage is still low. 14% of 13-to-17-year-olds have ever tried e-cigarettes and 9% are current users. If you filter the results just for smokers, you find that 32% of those who have ever smoked and 47% of those who still smoke use e-cigarettes.

Since the number of smokers is much greater than the number of vapers, and the number of non-smokers who take up vaping is extremely small, it seems intuitively obvious that it is more likely smoking that leads to vaping rather than the other way around.

It also seems obvious based on the experience of adult vapers. Adults start using e-cigarettes for various reasons, and quitting tobacco entirely may not be part of that plan. Many of them find, however, that once they start using second-generation e-cigarettes (battery and tank systems or “mods” with rebuildable atomizers), they can no longer tolerate tobacco cigarettes.

Why would this experience be any different for children, who have had less time to build up a tolerance to tobacco smoke? Why would anyone who started out with fruit-flavored or candy-flavored vapor decide to switch to inhaling smoke?

I can understand why someone who was already addicted might not find cigalikes compelling enough to be able to make a switch, but someone who has only experienced e-cigs will not have that problem.

That, however, is anecdotal evidence and speculation. What we need and don’t have is proof, and the only way we will get proof is by conducting longitudinal studies. A longitudinal study follows the same group of people for a number of years in order to see what happens. Someone needs to conduct a study of a statistically valid sample of teens to see what happens. Do the ones who never smoked before but start vaping turn to tobacco cigarettes? Do they continue vaping? Do they quit? Do the ones who started out as smokers switch to vaping? Do they become dual users? Do the dual users ever commit to one medium or the other? How many quit entirely? How many of those who vape reduce their nicotine levels substantially?

If e-cigarettes are outlawed, no long-term studies will be possible. We will never know about the health effects of vaping for five, ten, twenty years. We will never know whether teenagers move from vaping to smoking or from smoking to vaping. We will never know whether e-cigarette advertising “re-normalizes smoking” or simply creates a trend for vaping.

The best thing for young people is not to start smoking. Or vaping, either. But what about the ones who already have? Which product would you rather your child use?

And would you want your child to get arrested for using an e-cigarette when s/he could smoke without a penalty?