Californians have an opportunity on Tuesday to protect the health of their children by voting yes on Proposition 31, which would be a vote to prohibit the sale of nearly all flavored tobacco products in the state. It’s a much-needed move, and one that every state in the nation should be taking.
Flavored e-cigarettes have addicted a new generation of Americans to nicotine. In the past decade, the use of flavored e-cigarettes and other electronic nicotine delivery systems (ENDS) by youth and young adults, as well as by others who did not previously use tobacco products, has grown substantially, hitting a peak among high schoolers in 2019. Although use of these products dropped during the Covid-19 pandemic, their popularity is once again starting to rise. New data from the 2022 National Youth Tobacco Survey (NYTS) show that more than 2.11 million high school students, or just over 14% of all high school students in the United States, now use ENDS — an increase of 24% since 2021.
Adding flavors like fruit, candy, or dessert flavoring to an ENDS product increases the appeal by masking the harsh taste of chemicals. When teens are offered an ENDS product by their peers, they are six times more likely to accept a fruit-flavored ENDS compared to a tobacco-flavored product. According to the 2022 NYTS, 85% of middle and high school students who vape used flavored products, with fruit flavors being the most popular.
Prohibiting flavored ENDS products would be a powerful strategy to decrease the appeal to youth and young adults.
Decreasing the appeal of these products must be an urgent public health priority. As cancer specialists, we are deeply concerned about the growing use of ENDS because teens and young adults who might not have used traditional tobacco products are now using ENDS, risking addiction to nicotine which, in turn, may lead to the long-term use of combustible tobacco.
Smoking tobacco remains the leading preventable cause of cancer diagnoses and deaths globally. As long as ENDS are available to youths and young adults — and they are — policymakers have an obligation to prevent another generation from suffering from preventable illness and premature death that often unfortunately follow.
In late October, our organizations, the American Association for Cancer Research and the American Society of Clinical Oncology, released an updated joint policy statement published in Clinical Cancer Research and the Journal of Clinical Oncology calling for urgent action to prevent further nicotine addiction that includes a ban on all flavored ENDS products, stronger regulatory enforcement by the Food and Drug Administration, taxes on ENDS products, curbs on predatory tobacco advertising practices, and additional research to understand the long-term health impacts of ENDS use.
A review of new data published in JAMA Network Open indicates that vaping exposes individuals to carcinogens that may increase long-term cancer risks, even if at levels far lower than measured with combustible tobacco. Additional preliminary evidence links ENDS to DNA damage and inflammation, which are key early steps in cancer development. The potential carcinogenic risks of ENDS cannot be ignored.
The use of ENDS products by otherwise non-smoking, non-nicotine-addicted youth and adults also jeopardizes decades of advances against tobacco use. Young people who use ENDS are roughly three times as likely to begin smoking traditional cigarettes compared to peers who do not use ENDS.
Some have argued that the use of ENDS could help adults who currently smoke to quit. But there is little scientific evidence showing that ENDS products aid in tobacco cessation, a conclusion echoed by major health authorities including the U.S. surgeon general, the National Academies of Sciences, Engineering and Medicine, and the U.S. Preventive Services Task Force. Furthermore, no ENDS manufacturer has yet submitted an application to initiate a tobacco cessation study.
This dearth of data leaves people with opinions, but little evidence on which to base recommendations. That is why our organizations support conducting clinical trials of ENDS for smoking cessation with the appropriate regulatory review. We also urge health care providers to support existing evidence-based smoking cessation approaches, such as FDA-approved medications and behavioral therapy.
As professionals in the cancer field, we see the devastating impact of tobacco use, which stands between us and our shared goal of preventing and curing all cancers. To avoid a predictable and preventable tragedy, regulators should continue vigilant oversight over all tobacco products. We urge policymakers to follow the evidence and implement policies that limit the appeal and availability of these harmful products, keeping them out of the hands of young people and adults who do not already smoke.
Voting yes on Proposition 31 would be powerful step in that direction and would protect public health.
Margaret Foti is the chief executive officer of the American Association for Cancer Research. Clifford A. Hudis is an oncologist and the chief executive officer of the American Society of Clinical Oncology.
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