Is there evidence to support or refute this claim? Will many vapers who have stopped using cigarettes return to tobacco if they can only access menthol and tobacco-flavoured liquids?
There are very few published studies that help predict how vapers will respond to a ban on flavours. Many studies (including consumer research in Canada) have looked at the role of flavours in inducing trial and in maintaining use, but few have yet been published that look at how vapers responded when flavours were taken off the market. More than a year has passed since vaping e-liquid flavour bans came into effect in four New England states, and a summary of research on the experience in those jurisdictions is discussed below.
With little available research on the observed effects of such a regulation, governments are offered consumer research on the potential effects. This blog looks at two newly-published independent studies prepared by research teams which have to date been supportive of e-cigarettes. In both studies the researchers concluded that their studies did not support a prediction that vapers would revert to smoking if flavours were banned. Other relevant research conclusions and recorded experiences with state and provincial flavour bans are also presented.
1. The ITC research group found a majority of vapers are opposed to flavour restrictions but only a few of those who are not already smoking say they would return to tobacco.
The ITC Consortium surveys smokers and vapers on at least an annual basis. In February last year, they surveyed their panel of smokers and former smokers in the United Kingdom, the United States and Canada and asked those who vaped non-tobacco flavours what they would do if a ban on flavours other than tobacco and menthol came into effect.
The question was relevant to only a very small fraction of the smokers and vapers in the Canadian ITC panel. Of the 3,688 Canadians on the Canadian ITC panel who are already using nicotine, 250 were included because they were never-smoking regular vapers who were not using menthol or tobacco flavours. Of these 250 Canadians, only one-fifth (21.5%) were not already smoking at the time of the survey, giving a small sample size of Canadians around 55 people.
More exclusive vapers would stop vaping than would start smoking
Country-specific results were not provided, but for the 3 countries only 10.1% of this smaller group said they would move from vaping to smoking if flavours were banned. A larger number of those who do not smoke (14.5%) said they would give up vaping.
Country-specific results were not provided, but for the 3 countries only 10.1% of this smaller group said they would move from vaping to smoking if flavours were banned. A larger number of those who do not smoke (14.5%) said they would give up vaping.
Among dual users, 1 in twenty would stop smoking and vaping, 3 in 10 would give up vaping
Of those who were currently using both tobacco and vaping products, one-third said they would stop vaping if flavours were restricted, including 5.4% who said they would give up both smoking and vaping.
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| Annotated Figure 4 from Gravely et al, 2021 |
The 19 authors of this study did not predict that a ban on vaping flavours would result in net public health harm. They concluded: "At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses."
This research team did not map their results onto the Canadian market. This can be done if 5 assumptions are accepted:
1) that this cohort represented Canadians at large,
2) that vapers' actual actions will reflect their stated intentions,
3) that the Canadian Tobacco and Nicotine Survey gives an accurate representation of vaping and smoking patterns,
4) that dual use is more harmful than only smoking and only vaping, and
5) that vaping is less harmful than smoking.
If these assumptions hold, a ban on flavours other than mint-menthol and tobacco would result in 16,000 more Canadians exposed to the harms of tobacco and 159,000 fewer exposed to the harms of vaping.
- 17,900 fewer smokers (5.4% of 337,500 dual users whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop smoking and vaping)
- 34,400 additional smokers (10.1% of 337,00 former smokers whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping and start smoking instead.
- 92,100 fewer dual users (27.5% of 331,500 dual users whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping)
- 49,000 fewer vapers (14.5% of 337,00 former smokers whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping and not re-start smoking)
These results are in addition to any impact on the one-third of Canadian vapers who have never smoked cigarettes, and whose opinions were not included in the ITC survey.
2. An experiment with U.K. smokers found that those who were moved to a flavourless e-cigarette were no more likely to want to smoke cigarettes than those who used flavoured liquids.
Researchers at the Universities of Bristol and Cardiff and the U.K. government agency Public Health England recruited daily smokers who were not thinking about or trying to quit smoking. Smokers were randomly assigned to using an e-cigarette with a fruit flavour or using one with no flavour at all, and asked to refrain from smoking for a period of one week (which 85% were able to do).
The researchers found no differences in cravings or ability to remain abstinent for one week. "Contrary to our hypothesis ... We did not find evidence to indicate an effect of e-liquid flavouring on smoking lapse occurrence (during the study week), enjoyment of the e-cigarette, ease of transitioning from smoking to using an e-cigarette, intentions to continue using an e-cigarette, intentions to quit smoking, motivation to quit smoking (after study week) and return to smoking and continuation of e-cigarette use (1 week follow up).These findings suggest that, during an initial switch from smoking to using e-cigarettes, there may be little impact of using unflavoured e-liquids on cigarette craving if fruit/sweet-flavoured e-liquids are restricted."
They did find that those who were assigned to flavoured liquids used their products almost twice as long during the week (101 vs. 55 minutes).
3. California vape-shop customers who did not use tobacco-flavours were not more likely to say they would switch to combustible cigarettes if other flavours were banned.
Researchers at the University of Southern California looked at differences in response to flavour bans by level of e-cigarette dependence, flavour preference, and perception of harm. They recruited 276 participants for their survey at vape shops. While their main focus was impact on purchasing vaping liquids, they also analyzed whether vapers said they would return to e-cigarettes. They found that "flavour preference was not related to intention to switch to combustible tobacco products in the case of a flavour ban (p=0.71, results not shown), suggesting that flavour bans could deter users with flavour preference from using combustible products."
Generally, they concluded that a flavour-ban would provide public health benefit: "Customers who preferred flavours were less likely to intend to continue vaping in the case of a flavour ban, suggesting that flavour bans could reduce vaping among experimental tobacco users, without preventing highly nicotine-dependent users from switching from cigarettes to e-cigarettes for harm reduction."
4. Even without flavour restrictions, a large portion of Canadian former smokers who vape relapse to smoking.
As reported here earlier, this fall Health Canada released the third of a series of reports prepared by Environics which follow a group of Canadian vapers every 12 months. After one year, Environics found that 26% of former smokers had returned to cigarettes at the end of the first year. In the next wave of the survey, almost a third of those who had remained non-smokers for the first year had relapsed to smoking (6% of 20%).
The study also found that tobacco flavour is increasingly preferred by this cohort over time - with almost half of vapers who used to smoke identifying this as their preferred flavour . "Compared to previous waves of the study, preference for tobacco flavoured vaping liquids has increased,
overtaking fruit flavours as the most common choice among Regular Vapers. Tobacco flavour preference
is especially high among former smokers who still vape (46%), suggesting that many of these users have
replaced smoking with vaping products to give an experience that more closely resembles smoking."
Other recent research has identified that long-time former smokers who take up vaping are twice as likely to relapse to smoking as former smokers who do not vape.
5. Jurisdictions which have banned vaping flavours have not seen a significant increase in cigarette sales.
Only a small number of jurisdictions have implemented bans on e-cigarette flavours. In North America these include Massachusetts (November 2019), New York (May 2020), Rhode Island (March 2020), New Jersey (April 2020), Nova Scotia (April 2020), and New Brunswick (September 2021).
To date there have been no reports of large increases to cigarette sales following these bans. Because the few jurisdictions that introduced flavour bans did so immediately prior or during the COVID-19 pandemic, conclusions about the impact of the ban on tobacco sales need to consider this additional important event. Another complexity for analysis is the likelihood that sub-national flavour bans have little real effect on vapers because they continue to be able to purchase products from out-of-province/state online retailers.
- Massachusetts: cigarette sales went down after tobacco and vaping flavours were banned
A review prepared by a prominent advocate for vaping found after Massachusetts implemented both a tax and a flavour ban on tobacco and e-cigarettes, "there was no significant decrease in e-cigarette purchasing in the Greater Boston convenience market area as compared to the prior year’s purchasing patterns. We also found that there was a decrease in cigarette purchasing relative to the previous period immediately after the implementation of the tax; it is presumed that this is due to the ban on flavored tobacco products." (emphasis added)
Article at: Katchmar, A., Gunawan, A. & Siegel, M. Effect of Massachusetts House Bill No. 4196 on electronic cigarette use: a mixed-methods study. Harm Reduct J 18, 50 (2021). - Nova Scotia: cigarette sales went up the year vaping flavours were banned, but by less than 1%
Health Canada reports that the sale of cigarettes in Nova Scotia went up by less than 1%, compared with a national decline of -3.22% in 2020. This contradicts claims by the Vaping Industry Trade Association that smoking in Nova Scotia went up during this period.
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| Data provided by Health Canada, 2021 |
6. Other studies produce mixed results
A few other research findings are helpful to understanding the potential response to a flavour ban.
- Several years ago, John Buckell and his Yale University colleagues conducted a discrete choice experiment with American smokers and vapers, asking them to respond to removal of flavours in cigarettes and e-cigarettes. With these options, participants reacted to proposals to ban flavours in e-cigarettes, but allow menthol in cigarettes, by saying they would turn to cigarettes. To proposals to remove menthol from cigarettes, but allow flavours in vaping products, they said they would turn to vaping products. To proposals to only allow tobacco-flavoured in both, their response was mixed: on average, there would be a drop-off of 1 in 20 users, with 8% fewer coming from those who vaped counter-balanced by 3% who would smoke. None of these conditions reflect Health Canada's proposals to allow menthol in e-cigarettes, but to continue the long-standing ban on menthol in cigarettes.
- Researchers in Washington D.C. used results from a longitudinal survey of young adults (aged 18 to 34) in selected U.S. urban centres. Unlike the ITC study reported above, this survey included people who used nicotine and those who did not. Like the ITC study reported above, this survey asked participants about their support for flavour restrictions and vapers were asked how they would respond if flavour bans were put in place. Overall, support for a flavour ban was neutral, with e-cigarette users opposing and non-users supporting. Like the ITC study, some vaper participants reported that they would quit entirely, some reported that they would use cigarettes.
The researchers reported that their findings had mixed implications: "Current findings regarding young adults’ perceptions of sales restrictions on flavored vape products and on all vape products indicate that such policies may not only have a positive impact (ie, reduced e-cigarette use prevalence) but also underscore the potential for no impact (ie, continued e-cigarette use) or negative impact (ie, switch to cigarettes or dual use). Those most likely to perceive positive outcomes of such policies being implemented were less frequent users, never smokers, and those with greater e-cigarette-related health concerns. Moreover, nonusers reported mixed support for such policies, with e-cigarette users indicating low levels of support. This research is timely given the movement toward implementing e-cigarette sales restrictions and can inform future tobacco control initiatives."
