CASAA is currently putting together analytic and position statements about several of the burning topics in the the current THR debate. Our plan is to create drafts, put them out for peer review and member comments, and then post the final official version. Below you will find the first of these, posted here for comments. We welcome peer review comments on the empirical and analytic sections from anyone with expertise, and comments on the position statement from any CASAA members. Suggestions are also welcome on the labeling of the sections (which we are not thrilled about) and what to even call these. Something along the lines of “position statement” is typical, but it also implies that it is purely opinion which, as you will see, is not the case — it is mostly scientific analysis. (As with any review, of course, we will probably not act on every suggestion, but we will definitely consider them all.)
We believe these statements will be useful for people who are involved in the growing number of local fights about e-cigarette regulation and are otherwise engaged in attempts to educate. To that end, we include a first section which is the sound-bite version of the material that follows. We think the longer versions will be useful background for more serious conversations. A lot of the analysis we are including is often talked about, but has not been usefully consolidated anywhere.
**DRAFT** CASAA analysis of and position statement about underage use of e-cigarettes
[This draft version is for review. It is not CASAA’s official position. The final version will be published soon.]
Despite a lot of hype, the evidence shows that few minors are even trying e-cigarettes and few, if any, are actually using them. The CDC statistics that have been spun as “underage usage has doubled” actually only showed that the number of children who had ever taken one puff doubled, which is basically inevitable given the newness of the product. Moreover, it is clear that most of those trying e-cigarettes are already smokers, so the e-cigarettes may be playing the same harm reduction role for children that they do for adults, and there is no evidence at all to suggest that e-cigarettes are causing children to smoke. The reason that some people become worried about underage use is because they mistakenly think that e-cigarettes post similar risks to cigarettes. To the contrary, of all the indulgences that children could be engaging in, e-cigarettes are among the most benign, and thus are probably reducing total health risks.
A huge amount concern has been expressed about people under the legal age for use of tobacco products (hereafter: children) using e-cigarettes. This is similar to historical attacks on other low-risk tobacco harm reduction (THR) products, specifically smokeless tobacco, though is rather more aggressive due to the relative novelty of the products. It is clear that most of this noise is pure political strategy by people using it to serve other agendas, looking for any excuse to restrict or ban adult access to any tobacco product. The claims are groundless, in that they are scientifically false as well as expressing concern about a non-issue.
Contrary to the claims, there is basically no evidence that children are using e-cigarettes. What evidence exists is entirely about children trying e-cigarettes. In particular, despite the misleading rhetoric they packaged it in [http://www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html], the CDC’s recent survey data on children and e-cigarettes was restricted to trying an e-cigarette ever (perhaps as little as one puff) or trying one within the last 30 days (again, possibly just one puff) [http://www.cdc.gov/MMWr/preview/mmwrhtml/mm6235a6.htm].
These metrics clearly exaggerate the phenomenon. Perhaps that is intentional, though it might just be blind repetition of measures used for other drugs, but either way it is the wrong measure. A puff on a cigarette in the last 30 days is reasonably predictive that someone is a smoker, since the rate of daily smoking is about half that of “last 30 day” smoking and about a third of children who try one puff become daily smokers. One incident of taking meth or cocaine is troublesome, even if it is just one. But it seems likely that one puff on an e-cigarette is often just that: a smoker trying one once to see if it works for her, or kids at a party passing one around as a lark — a lark that happens to be substantially less hazardous than many other things many of them will do that night.
The most hyped claim from the CDC data, that “use” doubled between 2011 and 2012, referred to only the “one puff ever in your life” statistic, despite the fact that the CDC defined “use” as “one puff in 30 days.” Relative measures, like “double,” are often used in propaganda to hide the fact that the absolute numbers are unimpressive. Among high school students (some of whom are old enough to legally buy tobacco), the number who tried an e-cigarette in the last month was less than 3% and for middle school students it was 1%, though the numbers are often spun to imply that the larger figure also applies to the younger children. The number who made a regular practice of vaping is obviously smaller still, though CDC did not attempt to determine that.
The number who have tried an e-cigarette once is small compared to the number who smoke (i.e., actually do it as an ongoing practice, not merely those who have ever puffed a cigarette) [http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm] or have recently tried/used other drugs [http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm]. Indeed, the largest number in the e-cigarette results — that 10% of high school students had ever tried at least one puff (compared to less than 3% of middle school students) — is small compared to the number who have used other drugs in the last month: About 15% of high school students and 7% of middle school students have smoked in the last month; about 20% of high school students and several percent of middle school students have drunk alcohol in the last month; for illicit drugs the estimate for all children is in the range of 10%.
The fact that the “ever tried” statistics increased is not only unsurprising, but inevitable. E-cigarettes only entered the popular awareness and became widely available in the last few years. The only direction that “ever tried” could possibly go is up: if one child tried one puff on an e-cigarette in 2011 and one of his classmates did so in 2012, the prevalence of those who had ever tried a puff doubles (but notice that the incidence rate of trying did not increase at all and it might only represent two total puffs).
Perhaps most important, it is clear from the CDC data and further research [http://www.jahonline.org/article/S1054-139X%2813%2900748-9/abstract] that almost all of the children trying e-cigarettes are already smoking. In the e-cigarette report, the CDC only reported data for trying of cigarettes, as they did with e-cigarettes, and not all of those who had puffed a cigarette in the last 30 days are smokers, but smoking is likely to be an everyday practice for most of them and a frequent practice for many of the rest, in contrast with experimenting with a novel alternative. Thus, e-cigarette use among children seems to be playing the same role as it does for adults, harm reduction. But even if the harm reduction was unintentional or turned out not to be effective, it is still important to realize that most of those experimenting with e-cigarettes would have been smoking instead if the e-cigarette were not available.
A specific common claim, including by the CDC, is that children are trying e-cigarettes and this is causing them to become smokers when they would not have otherwise have done so (the standard anti-drug “gateway” story, which we address in a separate statement). There is no empirical evidence whatsoever that this is occurring. Indeed, we are not aware of a credible report of it having occurred even once (note that the mere fact that someone tried an e-cigarette before taking up smoking does not mean that e-cigarettes caused the smoking — you need to know a lot more to rule out the more likely possibility that the smoking would have occurred absent the e-cigarette).
Children experiment with drugs, sex, and other behaviors despite the wishes of many adults. Any children who are inclined to experiment have little difficulty acquiring cigarettes and alcohol, despite age prohibitions, as well as banned drugs, so it is inevitable that they can secure access to e-cigarettes and any other low-risk tobacco products. Thus, onerous restrictions on adult access to e-cigarettes cannot possibly be justified based on children’s use.
The implication of the rhetoric is that e-cigarettes are purely additive on top of other indulgences, though the reality is almost certainly that they are a substitute for not just cigarettes but other boundary-pushing behavior. Even if they are additive, it is difficult to see much reason for concern (apart from the speculative and non-credible gateway claims). If the above numbers were the trend in use of a drug that was as dangerous as alcohol, cigarettes, or many other drugs, then the trend might warrant alarm. But the health risk from e-cigarette use is trivial and it is increasingly clear that people who use them have a relatively easy time stopping if they so choose. If they are a substitute for cigarettes (as they appear to mostly be), or for other drugs like alcohol that pose serious physical threats or impair judgment and driving ability (the greatest threat to young people from all but the most rare and extreme drug behaviors), then the net effects are beneficial. Of all the ways to break the rules or engage in a bit of mild drug use, there are few that are more benign than e-cigarettes.
It is worth addressing, as an aside, the frequent claim that e-cigarettes facilitate vaping of cannabis and that this somehow poses a threat to children. The obvious responses to this are that while some pieces of expensive “mod” e-cigarettes can be used in rigs that can vaporize cannabis-containing oil, the cheap, widely-sold e-cigarettes cannot be repurposed in that way without substantial re-engineering. Moreover, there is the obvious absurdity of the implicit claim that a child who has secured access to a supplier of cannabis would somehow not have access to a device for consuming it were it not for e-cigarettes. It is obvious that the availability of e-cigarettes is not going to create any demand for cannabis.
The current empirical evidence is that children are not using e-cigarettes to any substantial degree. However, any honest and realistic projection of the future suggests this will change. E-cigarettes, their next-generation variants, and other THR products will inevitably become as widely used by, and as easily available to, adults as cigarettes, alcohol, and cannabis are now. Under those circumstances, we would expect that the same substantial portion of children who experiment with and use those other drugs will consider THR products. But because of the above analysis, this poses little reason for concern, and indeed some reason for hope that they will contribute to reducing harm.
Based on the above analysis, CASAA does not believe there is any reason for serious concern about children experimenting with e-cigarettes. Moreover, we believe that it is almost certainly the case that such experimentation has a net health benefit because it largely substitutes for harmful alternatives. However, we actively support prohibitions on sales of e-cigarettes to children and encourage merchants to voluntarily enforce such restrictions even when they are not required by law. We similarly do not object to regulations that make it more difficult for children to use e-cigarettes without creating a significant burden on adults, such as prohibiting possession in schools. (We generally object to criminalizing status offenses for children, but this is sufficiently tangential to our mission that we would likely never take an active role regarding such policies.)
We realize that if – as the evidence and science suggests – e-cigarettes are actually reducing children’s health risk from cigarettes and other drugs, such prohibitions are actually bad for the children. It is possible, however, that this problem will be somewhat self-correcting. Given the fact that children do find a way to get their hands on cigarettes and other forbidden products, those children who want to use e-cigarettes as a low-risk substitute for smoking will probably find some way to obtain them, just as they did for cigarettes. Moreover, the ban on underage use might make them more attractive to many children who might dismiss them if they were officially declared to be the legal alternative to smoking.
The main reason for supporting such bans is the political reality that they are important for protecting adult smokers’ access to e-cigarettes, which is the most important role for e-cigarettes. The specter of children using e-cigarettes is an effective strategy for those who want to prevent adult smokers from switching to low risk alternatives (and they know that, as evidenced by their active opposition to bans on sales of e-cigarettes to minors [https://antithrlies.com/2013/04/25/who-leads-the-fight-against-banning-e-cigarette-sales-to-minors/]). It is clearly unfortunate that such restrictions will cause some children who might have used e-cigarettes to smoke instead, but at least they would have legal access to a low-risk substitute when they reach majority. The current political climate means that intentionally denying children access to THR serves the greater good.