When the U.S. Food and Drug Administration banned fruit-flavored vaping products in early 2020, the idea was to reverse the rapid rise in electronic cigarette use among youths.

Now, a new survey of adult e-cigarette users finds that instead of quitting e-cigarettes, most vapers switched to flavored products not covered by the ban, or even went back to smoking traditional cigarettes.

The ban does not appear to be working and use of flavored products continues, contends study co-author Deborah Ossip. She’s a professor in the department of public health sciences and Center for Community Health and Prevention at the University of Rochester Medical Center (URMC) in New York.

“It really gets to the issue of, if you want to meaningfully restrict the use of flavored products, you really need to close those loopholes,” Ossip said. “And to combine that with the program of enforcing the regulations, and I think a very large public awareness campaign about why that’s happening, because there’s a lot of confused messaging around use of flavored products and e-cigarettes.”

The FDA ban was on products using flavored cartridges and pods. It did not include tanks. It also did not ban disposable, flavored e-cigarette products that soared in popularity after the ban.

Menthol products were also not part of the ban, said lead study author Dongmei Li, an associate professor of clinical and translational research, obstetrics and gynecology and public health sciences at URMC.

“We wanted to see whether after the implementation of this policy, the problems of the e-cigarettes had decreased and also was there user behavior change after the policy. Does the policy really help to reduce the e-cigarette use?” Li said.

“Many people switched to menthol flavor e-cigarettes, and some people, they mentioned on social media … the FDA flavor ban makes them realize how good the menthol flavor is,” Li added.

The URMC survey was conducted online in July 2021 and included more than 3,500 participants.

The survey found that nearly 30% of survey respondents switched to using tank or disposable flavored e-cigarettes. Another 30% switched to menthol or tobacco-flavored pods. About 14% switched to combustible e-cigarettes. About 5% of people switched to smokeless tobacco products.

Fewer than 5% of those surveyed actually quit smoking.

“The flavors themselves really serve two rather dangerous purposes,” Ossip explained. “One is they lure particularly young people into using e-cigarette products. And once they do, because of the nicotine in the e-cigarettes, they are highly likely to become addicted.”

Then, she added, “The second concern about flavors is that there are thousands and thousands of flavors out there. They keep evolving. People mix flavors. A cherry flavor from one manufacturer will have a different chemical composition from another, but what we know of the flavors that have been studied is that flavors carry their own toxicities,” Ossip said.

Li pointed out that reasons drawing people to e-cigarettes include the impact of social media, curiosity, their sleek design and easy access.

“Posting education messages on social media that tell the youth and young adults about the harm of the flavored e-cigarette use is very important,” Li said, noting that pro-vaping messages on social media include videos showing people how to do vaping tricks or to mix flavors.

Research has shown that e-cigarette use is associated with COPD (chronic obstructive pulmonary disease), cardiovascular disease and cancer.

“One of the, I think, really sobering sets of findings about the dangers of e-cigarettes is that many diseases take a long time to develop,” Ossip said. “Lung cancer might take 20 years to develop, and e-cigarettes haven’t been around that long, and even at this early stage we’re still starting to see some relationships and increased risk of some of these diseases.”

Nicotine also changes brain development in youths and young adults, Ossip added.

The 2020 National Youth Tobacco Survey found that nearly 20% of high school students and 5% of middle school students were current e-cigarette users. In 2018, just over 3% of adults used e-cigarettes, with nearly 15% having ever used e-cigarettes, the study authors noted.

At the time of the FDA ban, the American Lung Association (ALA) was critical of the policy because it excluded some flavored products, said Thomas Carr, national director of policy for the ALA.

“I think that clearly what happened, at least some of what happened here, is that e-cigarette users migrated to other flavors, other types of products and flavors,” Carr said.

“That seems to be what happens is that, especially with kids, they follow the flavors. So, if the product is available in a flavor they like, they will switch to that product,” Carr said.

The lung association supports completely prohibiting the sale of all flavored tobacco products, including cigars and menthol cigarettes, Carr said.

“We think that will prevent a lot of switching that we saw that this study shows, but also what we’ve always seen just in a general context,” Carr added.

The lung association would also support the idea of lowering the nicotine level in e-cigarettes and combustible cigarettes, he said.

“We’ve gone on record with FDA and they are looking at that idea as part of kind of their regulatory agenda, at least as of now,” Carr said. “I think one of the things we have seen is that especially with youth, we’ve seen a really high level of addiction.”

Research has shown that low-nicotine cigarettes may help people quit, Li said, suggesting additional study on this possible solution.

The findings were published online recently in the journal Tobacco Control.

More information

The U.S. Food and Drug Administration has more on the 2020 e-cigarette flavor ban.

SOURCES: Deborah Ossip, PhD, professor, department of public health science and Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, N.Y.; Dongmei Li, PhD, associate professor, clinical and translational research, obstetrics and gynecology and public health sciences, University of Rochester Medical Center, Rochester, N.Y.; Thomas Carr, BA, national director of policy, American Lung Association, Washington, D.C.; Tobacco Control, Nov. 3, 2022, online