Would bans address youth vaping?

If you haven't seen it in the street, you've probably seen it on the news – teens are vaping. The proportion of young people who have experimented with vaping has increased by 50 per cent in just one year, with 12 per cent of youth having tried vaping at least once or twice, and 3.6 per cent vaping at least once a week.

Here in the Tobacco and Alcohol Research Group at the University of Bristol, we're interested in the psychological mechanisms which might be driving the increase in the popularity of vaping among young people in the UK. We want to understand which elements of vaping are specifically attracting them – is it the flavours, the colours, the packaging, the marketing, the availability?

Psychologists can not only help us to understand why people engage in behaviours like vaping, but they can also help us to encourage positive behaviour change. Psychological research has informed tobacco policies and public health interventions for decades, and now psychologists can use those skills and experiences to discourage the use of vapes among young people via behavioural interventions and also inform policy.

Among young vapers, the most popular vapes are disposable devices that are easy to use, colourful, flavourful and seem to have branding specifically targeted at an underage audience (Notley et al., 2022; Smith et al., 2023).

The dramatic increase in popularity is concerning because although vapes are less harmful than cigarettes and can be helpful while trying to stop smoking, they still contain some harmful toxicants and chemicals. Vapes can also contain nicotine and disposable vapes often contain high (and sometimes illegal) levels of nicotine. Many young people using these devices are at risk of becoming addicted and could be at risk of using other, more harmful, nicotine products too.

With increasing public pressure on the UK government to protect young people from vaping, UK Prime Minister Rishi Sunak has proposed a ban on disposable vapes and restrictions on attractive flavourings. But will these restrictions have the intended impact, or could they actually do more harm than good?

Let's first consider the impact of banning disposable vapes. These products are primarily used by young people rather than older adults who are using them to stop smoking, so in theory, this ban should not detrimentally impact public health efforts to be smoke-free.

However, it is already illegal for young people to buy vapes, and in our recent survey of 196 young people in the Southwest of England, 14 out of 42 who had tried vaping were able to illegally buy vapes directly from shops, and some were able to access vapes with illegal levels of nicotine. We've also seen reports from the BBC and ITV of young people using vapes that contain illegal levels of heavy metals and spice (synthetic cannabis), so we know that young people already have access to illicit products.

Rather than protecting youth from harm, banning disposable vapes while they are so popular, and while young people may be addicted to them, could just force them into a more dangerous illicit market.

Another suggested solution is to restrict the flavours available in vapes. These changes could be implemented in a number of different ways. First, by limiting the way flavours are described. Second, by limiting the ingredients. Third, by limiting the characterising flavours (i.e., the taste and smell) of vapes. Any of these options could limit to: only tobacco flavours; tobacco flavours plus mint and menthol flavours; or tobacco, mint menthol, plus fruit flavours.

Choosing which flavours to restrict could be difficult. In our recent survey of young people in the Southwest of England, the most popular flavours of vapes were fruity (apple being the most preferred) followed by cherry, watermelon, mango, pineapple, and raspberry. Other notable flavours included strawberry cream, sweet cream, blue raspberry, cola, and mint.

In an online study with young people, packages with flavoured descriptors (e.g., strawberry) versus unflavoured were preferred, but there was no clear difference in preference between candy/sweet flavours and fruit flavours (Dyer et al., 2023). This evidence might suggest that banning fruit or sweet flavours could be effective in reducing appeal to young adults; however, fruit flavours are also commonly used by adult vapers who use e-cigarettes to quit smoking and stay smoke-free. 

Our team have created a policy decision aid to help policymakers to assess whether banning non-tobacco flavours in vapes could have a beneficial or detrimental impact on the UK population in terms of youth vaping, and youth and adult smoking rates (Gibson et al., 2022).

We predicted the impact by taking evidence from existing nationally representative survey data to estimate the number of youth who vape because of the flavours (and those who may go on to smoke) and weigh this against the number of ex-smokers and smokers who would relapse or continue to smoke without flavours. We estimated that 39 per cent of smokers who might use e-cigarettes to stop smoking would smoke more or not quit smoking, and 14 per cent of ex-smokers who vape would relapse to smoking if their preferred flavour was restricted.

At a population level, this equates to more than half a million smokers and ex-smokers not smoking due to flavoured e-liquid availability; whereas less than 100,000 non-smoking youth experiment with e-cigarettes as a result of flavoured e-liquid availability and around 36,000 of those non-smoking youth might subsequently smoke as a result of flavoured e-liquid availability. This output suggests that restricting flavoured e-liquids in the UK could have a negative overall impact on public health.

We also found in our qualitative research that although some vapers and smokers would be supportive of partial or full restrictions to flavours, some vapers would be willing to source flavours illegally. Additionally, we have seen in other countries, such as Finland, that banning flavours other than tobacco does not stop the use of other flavours (Ruokolainen et al., 2022).

Other restrictions have been suggested, including limiting what is allowed on packaging and where vapes can be advertised. These restrictions could also result in unintended consequences, but potentially less harmful unintended consequences. But national restrictions may not be the most effective or safest way to protect young people who are vaping.

In focus groups with young people, they expressed a desire for more education on the harms of vaping, coming from a range of trusted sources (e.g., teachers at school, health influencers on social media). So, before the UK government rush to ban disposable vapes or flavours, they could consider a public health campaign and funding educational resources for young people so that they can make informed decisions. By targeting young people directly, we could tackle the issue without hampering efforts to achieve our smoke-free goals or forcing people to source vapes from a dangerous illicit market.

Find more from The Psychologist and Research Digest archives.

References

Dyer, M., Suddell, S., Khouja, J.N., et al. (2023). Do flavour descriptions influence subjective ratings of flavoured and unflavoured e-liquids among non-smoking and non-vaping UK adolescents?
Gibson, M.J., Munafò, M.R., Attwood, A.S., Dockrell, M.J., Havill, M.A., Khouja, J. N. (2022).
A decision aid for policymakers to estimate the impact of e-cigarette flavour restrictions on population smoking and e-cigarette use prevalence among youth versus smoking prevalence among adults.
Khouja, J., Dyer, M.L., Havill M.A., Dockrell, M.J., Munafò, M.R., Attwood, A.S. (2022). Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among UK smokers and smoking relapse among UK e-cigarette users: Findings from a qualitative study, PREPRINT (Version 1) available at Research Square.
Notley, C., Gentry, S., Cox, S., Dockrell, M., Havill, M., Attwood, A.S., Smith, M. & Munafò, M.R. (2022). Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation. Addiction (Abingdon, England), 117(5), 1258–1272.
Ruokolainen, O., Ollila, H. & Karjalainen, K. (2022). Correlates of e-cigarette use before and after comprehensive regulatory changes and e-liquid flavour ban among general population. Drug Alcohol Rev., 41: 1174-1183.
Smith, M. J., MacKintosh, A.M., Ford, A. & Hilton, S. (2023). Youth's engagement and perceptions of disposable e-cigarettes: a UK focus group study. BMJ open, 13(3), e068466.