The 2019 lunar new year was supposed to be an unlucky year for me based on Chinese astrology. I don’t usually give much weight to these horoscope-like predictions, but my awareness was heightened this year with my own wedding taking place earlier this month. Thankfully, it was a beautiful day, and I can report no wedding-related bad luck! This photo from the day before captures both that essence and the general message of this blog post: seeing the forest for the trees, or in this instance, the bigger tobacco control picture when it comes to e-cigarettes/vaping.

frame of a house

As I’ve worked to catch up from being out most of the month, I’m now convinced that my Chinese zodiac-predicted bad luck has more to do with keeping up on the growing number of vaping headlines and having to untangle the ever-evolving landscape that is tobacco control policy right now. The single biggest takeaway I’ve come to thus far is that the window of opportunity for game-changing tobacco control policy—even beyond e-cigarettes—is now. See, for example, this powerful argument for specifically articulating the tobacco “endgame” as phasing out sales of conventional cigarettes.

The headline-fueled narrow focus on e-cigarettes is understandable given the outbreak of mysterious vaping-related lung illnesses, including at least 12 deaths across ten U.S. states, and according to preliminary data from the 2019 National Youth Tobacco Survey and Monitoring the Future Survey, a disturbing increase in youth use of e-cigarettes in the U.S. for the second year in a row. The youth e-cigarette epidemic is really driving the current predominant policy solution being proposed and adopted at varying levels of government: restrictions on flavored e-cigarette products. A majority of youth e-cigarette users report using flavored products, and flavored e-cigarette products are believed to be a major reason for both initiation and sustained use of the products.

The outbreak of vaping-related lung illnesses has coincided with the youth e-cigarette epidemic, but only 16% of cases thus far have been in people younger than 18 years of age, which muddies the connection between the very clear problem of alarming youth use of flavored e-cigarettes and the proposed solution of restricting, and in some cases, entirely prohibiting such products. The scope of the outbreak is still developing, though, and while no single vaping product or substance has yet been identified as the specific cause of the illnesses, initial data suggests illicit THC vape products are connected to most cases. Confusing those illicit products with the nicotine-based e-cigarettes the U.S. Food and Drug Administration’s (FDA) Center for Tobacco Products regulates is problematic from both a legal and policy standpoint. The outbreak has certainly further cracked open the window of opportunity for advancing tobacco control policy, but without a clear understanding of the exact cause(s) of the vaping-related illnesses, it leaves the solutions to that specific problem unclear as well. In other words, a prohibition on flavored e-cigarettes—whether they contain nicotine, THC, CBD, or some other substance—is not likely to resolve the outbreak based on what we know about the cases thus far, but it could help reduce the skyrocketing rates of youth e-cigarette use.

The conflation of these two issues raises the question whether the narrow focus on youth use of flavored e-cigarettes is appropriate. The answer depends, of course, on how you define “appropriate.” If the only goal is to reduce youth use of e-cigarettes, the narrow focus may be appropriate, but the truth of the matter is that it’s more complicated than that. We live in a world where a variety of products are available, including what everyone agrees are the most lethal of all tobacco products: conventional cigarettes. In the U.S., over 34 million adults smoke conventional cigarettes still, and certain subpopulations disproportionately bear the burden of tobacco-related death and disease, which is still primarily a result of conventional cigarette smoking. This includes menthol cigarettes, which remain the only non-tobacco flavored cigarette legally available in the U.S.

To focus only on e-cigarettes, or even more narrowly, flavored e-cigarettes, and exclude other more lethal tobacco products like menthol cigarettes from the conversation is short-sighted, especially with the limited windows of opportunity that seem to open up for advancing meaningful tobacco control policy. Whether it’s educating about the larger context or being more precise about those devilish policy details (e.g. exactly which products are included in a policy’s definition of “e-cigarette,” whether a local flavor prohibition includes all tobacco products rather than just e-cigarettes or the soon-to-be-finalized FDA guidance on its tobacco enforcement priorities still includes flavored cigars as the March 2019 draft did), public health advocates should not limit themselves to a narrow focus on e-cigarettes. I committed to doing better about my own communication of the differential risks of tobacco products earlier this year and have been working hard to think through which tobacco control policies will have a net public health benefit. I admit that it hasn’t been easy and that it doesn’t always fit nicely into short, punchy soundbites, but as I continue to work on it, I hope others will, too.

*Photo credit: Kiku Enomoto