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<br />In recent years, the evidence around flavored
<br />tobacco product bans and restrictions has grown
<br />in terms of public support, public health and
<br />financial impact, and compliance. The purpose
<br />of this report is to provide an overview of the
<br />projected impacts of a policy that bans or
<br />restricts the use of flavors in tobacco products
<br />and to provide evidence-based policy
<br />recommendations for maximizing public health
<br />benefits and minimizing unintended
<br />consequences.
<br />
<br />BACKGROUND
<br />
<br />In 2009 the U.S. Food and Drug Administration
<br />(FDA) banned flavored cigarettes with an
<br />exemption for menthol additives. As intended,
<br />cigarette use among youth declined in the years
<br />following the ban; however, unintended
<br />consequences have emerged, with youth
<br />increasing their use of other products known for
<br />their flavors, such as menthol cigarettes, cigars,
<br />and pipes.1
<br />
<br />In this historical context, pod-based electronic
<br />cigarettes (e-cigarettes),* such as JUUL, have
<br />emerged as the tobacco product of choice
<br />among youth due to kid-appealing flavors (e.g.,
<br />mango and mint), discreet design (i.e., flash
<br />drive-like appearance), savvy social media
<br />marketing (e.g., social media influencers and
<br />celebrity endorsements), and extremely high
<br />nicotine levels with chemicals added to ensure
<br />the nicotine is less harsh to users. The totality of
<br />these factors has resulted in what many public
<br />health advocates have labeled an epidemic.
<br />
<br />* Claims that e-cigarettes are “95% less harmful” are from a 2014 academic paper endorsed and publicized by Public Health
<br />England and the Royal College of Physicians. By the authors own admission, “A limitation of this study is the lack of hard
<br />evidence for the harms of most products on most of the criteria.”2 Since this study was published, evidence has emerged
<br />suggesting e-cigarettes are not safe, particularly for nicotine naïve users. E-cigarettes harm cells, users, and increase the risk of
<br />smoking. The long-term health effects of vaping are not yet known though. The “95% safer” estimate is unreliable information
<br />repeated so often that it has been accepted as fact.3 Notably, one of the study funders, Lega Italiana Anti Fumo (LIAF), has
<br />previously worked with Philip Morris USA, and the Chief Scientific Advisor of LIAF was an author. They also previously
<br />consulted for Arbi Group Srl., an e-cigarette distributor.4
<br />† One well executed study suggests e-cigarettes in combination with cognitive behavioral therapy can help smokers quit.6
<br />However, there is no high-quality clinical trial evidence to support the idea that e-cigarettes can help smokers quit without
<br />these added professional health care services.
<br />Nationally, 3.6 million middle and high school
<br />students are reported to be current e-cigarette
<br />users (any use in past 30 days), with e-cigarette
<br />use among high-school students more than
<br />doubling from 2017 to 2019, increasing from
<br />12% to 28%.5 In Maryland, use in high schools
<br />has increased from 13% in 2016-17 to 23% in
<br />2018-19, representing an increase of 73%. For
<br />comparison, use among adults in Maryland
<br />increased from 3% in 2016 to 4% in 2018,†
<br />representing an increase of 34%.7
<br />
<br />To help combat this public health issue, in 2019
<br />the Maryland General Assembly passed HB1169,
<br />an evidenced-based bill that raised the minimum
<br />age of tobacco sale from 18 to 21 years old, with
<br />an exemption for 18-20 year old adults with a
<br />military identification. The strength of this bill
<br />will be aided with the recent signing of a 2020
<br />Federal appropriations bill that raises the federal
<br />minimum age to 21 and does not include an
<br />exemption for military service members. While
<br />these are positive steps, there are many ways in
<br />which youth can acquire tobacco products and
<br />the evidence available suggests compliance is
<br />highly unlikely to be 100%, with tobacco and
<br />vape specialty shops being the most likely to
<br />violate the law.8 These data suggest additional
<br />policy interventions, such as flavor bans or
<br />restrictions, may be necessary to prevent youth
<br />from using tobacco products.
<br />Broadly speaking, flavors are added to tobacco
<br />products to increase palatability and decrease
<br />harshness, which makes these products more
<br />appealing to youth and young adults.9 Flavors
<br />can be classified as 1) characterizing, such as
<br />mint/menthol, strawberry, chocolate, coffee,
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