Is it possible to create a regulatory environment and a culture that encourages adults who smoke to switch to vape without non-smoking teens taking up vaping as a hobby? The United Kingdom was a world leader in using vaping as a safer alternative for adults who smoke and had low teen vaping rates until 2022 and 2023 when teen vaping rates doubled. One reason may be the widespread availability of attractive-looking disposable vapes at “pocket-money” prices.

Does youth vaping matter matter? If so, what can be done about it?

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How bad is the problem?

Data from Action on Smoking and Health shows the increase in teen vaping rates, with “current vaping” (at least once per week) increasing from 3.2% to 7.6% of 11 to 17-year-olds.

The increase in caping is assumed to be due to the rise in disposable vapes that are sold at “pocket-money” prices. These products have gone from under 10% of the youth market to 69%, displacing both rechargeable refillable pod devices and rechargeable devices with disposable pods.

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How much does this increase in youth vaping matter, and what can we do about it?

How people answer this question is a bit like a Rorschach test. It offers a window into their soul, a clue about their philosophy of life.

Optimists, for example, turn the statistic upside down. 92.4% of youth in the UK are not vaping even once a week, so why the moral panic?

The Pollyanas say that vaping is just a fad, like hula hoops, Rubik’s cubes and iPods, that will soon pass. No need to worry!

The stoics and nihilists say there is nothing that can be done; we just have to put up with the situation. Draconian restrictions on vaping will only increase the size of a dangerous criminal black market. We cannot restrict the flow of unregulated products (such as Spongebob vapes) manufactured in China, sold on the Internet and delivered directly to consumers worldwide. Prohibition never works. It is what it is; live with it.

Paranoid people see teen vaping as a ploy by “Big Tobacco” to addict a new generation to nicotine products. They downplay the fact that vaping was invented by a chemist, that Juul was an independent company for most of its life, and that newer nicotine products are an existential threat to the tobacco industry. They could destroy “Big Tobacco” in the way that Netflix (and other streaming services) eliminated Blockbuster’s video rental business.

Libertarians and capitalists join forces and say that this is just the free market at work. Informed and autonomous consumers are choosing voluntarily to do something that brings them pleasure despite being aware of the risks.

Utilitarians would point out that teen vaping has been associated with a huge decline in teen smoking. As smoking is about 20 times more dangerous than vaping, teen vaping is a net benefit to youth.

Consequentialists accept that the end justifies the means. The main problem is people dying from cigarette smoking. Whatever works and saves lives is justifiable. Vaping seems to be a substitute for smoking, so it is a “good thing.”

Philosophers consider the issue a new variant of the “Trolley Problem.” If a train is on the tobacco track, it will kill 100 adults who smoke. If you pull a lever, it will switch onto the vape track and kill one teenager who is vaping. Do you pull the lever to save 99 lives? Or do you agree with FDA Commissioner Scott Gottlieb, M.D., who says that it is unacceptable for even a single child to die from complications of vaping, no matter how many adult lives are saved?

Idealists and prohibitionists argue for abstinence. No one should use any drug, including nicotine, ever. They have not learnt from the prohibition in the USA or from the “war on Drugs.”We should “Just say no” to their ineffective abstinence-only policies.

Pragmatists think that the major problem is the large number of adults who smoke and are likely to die as a result. They are puzzled that so much public attention is focused on the smaller number of youth nicotine users, who are mainly vaping and therefore at low risk of serious disease or death.

Others deflect and say that youth vaping is not the most important issue. Alcohol, opioids, distracted and impaired driving are the real problems that parents of teenagers should be worried about.

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I was puzzled by the way youth vaping had suddenly taken off in the UK. When I was at the E-Cigarette summit in London, I took a side trip to Norwich, a city 2 hours northeast of London with a population of about 200,000 people and five vape shops in the downtown core. In the UK, vape shops look just like any other store. They can openly display their products, put promotional posters in their window and offer sales.

In each store, there was a huge display of disposable vapes. Other products were on display, but by far the most space was devoted to disposables. The typical price for a disposable vape was £4 for a 600-puff disposable vape, which is roughly equivalent to a packet of twenty cigarettes that sells for £12.84.

Disposable vapes are competing with other small luxuries a teenager could afford. A “Big Mac” burger costs £4.99, two brewed coffees at Starbucks cost £5:20, and a pint of lager is £4:57. These items would be consumed in ten to fifteen minutes, but the vape would last all day and maybe even longer. A disposable vape is so cheap that if it were mislaid, stolen or confiscated, that would not be a significant loss.

Given the ready availability of such a wide range of nicely packaged products at low process, is it surprising that so many youth are vaping?

In theory, there is a legal age limit of 18, but clearly, young people have found a way to circumvent this law. More enforcement is needed.

Some people would argue that the youth who are vaping would otherwise have smoked so that they have actually reduced their risk. However, youth smoking rates have not been over 7% in the last decade, so at least some of the young vapers would likely never have smoked. Other people argue that, as vaping is very much safer than smoking, it only makes sense that more youth vape than would have smoked. There were probably people who would like to use nicotine, maybe even benefit from it for relaxation and concentration, but were put off because they did not want to take the risk of smoking cigarettes. Given the opportunity to use nicotine without the risk of smoking, they are taking it.

There are people who suggest that nicotine should be considered a legitimate recreational substance, along with caffeine, alcohol and cannabis. There is some merit in this argument. Nicotine is probably much less harmful than alcohol, which is a known carcinogen and a serious liver toxin. It also causes societal problems such as impaired driving and violence.

However, while most people can enjoy coffee, beer or a joint without suffering from significant health risks or social harm, there are some people who cannot. Some teens lose all motivation to work or study as a result of frequent cannabis use, and some users may develop a psychosis. Some teens may die from alcohol poisoning or become alcoholics. Even caffeinated sports drinks pose a risk to teen health. While the majority of teens are likely to be able to use moderate amounts of nicotine without ill effects, a minority will actually become addicted and find themselves needing to use nicotine regularly to avoid withdrawal symptoms. We certainly need to ensure that this group is supported and we need to develop better treatments for genuine nicotine addiction.

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How dangerous is vaping?

Unfortunately, even though it has been 20 years since vapes were invented and a decade since they became popular, there is no clear answer to this very important question. It is easy to shut down any discussion on vaping by saying “We do not know the long-term risks”. Health organizations around the globe should be embarrassed about this. (Full disclosure: I was hired as a physician for the Canadian arm of a global study on the topic, organized by COeHAR and funded by the Foundation for a Smoke-Free World. The study was cancelled when Philip Morris International reduced its funding to the Foundation).

In the short term, vaping causes minor side effects such as coughing and a sore or dry throat. Heavy use of vapes results in nausea that discourages users from continuing, long before they reach dangerous blood nicotine levels. The claims that vaping causes lung injuries such as EVALI or Popcorn Lung have been debunked. Some young people do develop seizures or a spontaneous pneumothorax (“burst ling”) at about the time they vape, but both these events also occur in young people who have never vaped, so this is likely a coincidence.

Public Health England has said that the risks of vaping are “unlikely to exceed” 5% of the risk of smoking. Given that 60% of long-term smokers die of a smoking-related disease, this would suggest that up to 3% of long-term vapers might die from vaping. This seems an improbably high percentage. The risk is hard to calculate as smoking has three modes of lethality: cancer, lung, and cardiovascular disease. The risk of cancer from vaping has been calculated as 0.4% of the risk from smoking. I am unaware of any accurate comparable figures for heart and lung disease risk.

How can we reduce teen vaping?

It is reasonable to be concerned about teen nicotine use and to try to limit it, but it is difficult to see how this can be achieved. A traditional public health approach would begin by ensuring teens know the risks. The problem with this approach is that teens already vastly overestimate the risk of vaping. Thanks to alarmist media coverage, 54% of youth already think that vaping is more dangerous than smoking cigarettes. If they were aware that vaping does not cause popcorn lung and that EVALI was due to illegal contaminated THC products, not nicotine vaping, then maybe even more of them would vape.

The kneejerk authoritarian response is to ban something. Ban flavours insist on plain packaging, ban disposables, ban all vaping…

Many countries already have a total prohibition on vaping, but this does not prevent an illegal trade. In Australia, where nicotine vapes are only allowed on prescription, teen vaping rates are the same as in New Zealand, where vaping is legal and encouraged as an alternative to smoking.

It is hard to argue that the wide range of exotic flavours with enticing names is needed to help adult smokers switch to vaping, but both teens and adults prefer vape that has a fruit or dessert flavour and dislike unflavored or tobacco-flavoured products. One could reasonably restrict vaping to a half-dozen flavours with simple names like “mango,” “mint,” or “Cheesecake.” This may be a reasonable response to the critics of flavours, but it is unlikely to have a major effect.

In a similar fashion, one could restrict the design of vape packages. They should not be made deliberately unsightly like many “plain package” tobacco products, as adult smokers should not be discouraged from using them, but they could be made plainer, simpler and less enticing. Again, this small step may respond to common criticism but is unlikely to result in a huge change.

In Canada, vape shops must hide their products from people under the age of 18. They cannot display vapes in a shop window where anyone passing by can see them. Advertising of vapes is also strictly controlled. These measures have not prevented youth from vaping. In 2022, the CTNS survey showed that 14% of youth aged 15-19 had vaped in the last 30 days (but only 4% smoked).

Should disposables be banned or heavily taxed?

Banning disposables would seem to be an obvious solution, as they are a significant part of the problem, and they are very wasteful and environmentally damaging. However, many adult smokers find disposable vapes very convenient, especially if they are old or disabled and have difficulty using charging cables or changing pods. Disposables are an easy way for adults who smoke to test-drive vaping without a large upfront expense. If they break or lose their regular rechargeable vape, disposables are a much better option than buying a packet of cigarettes.

It is likely that a ban on disposables would be impossible to enforce and just create an unregulated black market. It already seems impossible to control the flow of illegal and potentially harmful disposable vapes that are marketed on the Internet and shipped directly to consumers by mail from China.

Perhaps the only effective option is to increase the price of disposable vapes by adding a significant tax. This is currently being planned in the UK. Vapes should always be cheaper than cigarettes, but they do not need to be 1/3 of the price. Even if they were 50% cheaper than smoking, this would be a good incentive to encourage adult smokers to switch. Higher prices create an opportunity for the development of an unregulated black market, which is a very real and significant concern.

Conclusion

Public health is perpetually fighting a rearguard action against capitalism. While the overriding obligation of corporations is to return profits to their shareholders, they will always do so, even at a substantial risk to public health. This applies to all companies, not just the tobacco, vaping and nicotine industries. The rise in teenage vaping that started with Juul and has now been resurrected and reinforced by disposable vapes. Public health has some weapons that it can use, such as enforcing bans on underage sales, restricting product display and advertising, and taxation, but businesses and consumers will always try to circumvent any restriction or regulation.

Safer nicotine products have already saved millions of lives, and will continue to do so wherever they are available. One of the best things we can do for our children is ensure that they grow up in homes with living, healthy, non-smoking parents.