Research & Commentary: Largest Vaping Survey Finds Flavors Play Important Role in Tobacco Harm Reduction

Published October 2, 2018

In the largest vaping survey, consisting of nearly 70,000 American adult vapers, researchers found that flavors play a vital role in the use of electronic cigarettes and vaping devices. Lead authors, Dr. Konstantinos Farsalinos, research fellow at the Onassis Cardiac Surgery Center in Athens, Greece, and Dr. Christopher Russell from the Centre for Substance Use Research, Scotland, U.K., conducted the study and designed the online questionnaire that was “open for participation from April 3rd to May 2nd,” 2018.

The authors conducted the survey in response to the U.S. Food and Drug Administration’s (FDA) March 2018 Advanced Notice of Proposed Rulemaking. FDA sought public information “related to the role that flavors play in tobacco products.”  

Of the 69,233 vapers in the study, the authors noted that “almost 95% of participants reported that they were ever smokers,” and only 5.2 percent “reported being never smokers.” The authors also found that nearly 92 percent of former smokers had used electronic cigarettes and vaping devices at the time of quitting.

Furthermore, the authors found that many e-cigarette users cited using flavors at the point of initiation. On the other hand, only 20 percent of survey respondents reporting “using tobacco flavors,” at the point of initiation. The authors also found tobacco flavors to be “more prevalent among current [smokers] compared to former and never smokers.”

This study provides further evidence to the role that flavors play in helping smokers quit combustible cigarettes and is consistent with earlier findings. A 2013 internet study by Dr. Farsalinos concluded that flavors in e-cigarettes “appear to contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking.” A 2015 online survey conducted by the Consumer Advocates for Smoke-Free Alternatives Association surveyed 27,343 Americans over the age of 18 on their use of vaping devices. Of the respondents, 72 percent “credit[ed] interesting flavors with helping them quit.” Of the respondents still smoking, “53% say interesting flavors are helping move them toward quitting.”

On the role of tobacco flavors in e-cigarettes, a 2017 study noted in older adults “use of an e-cigarette flavored with something other than tobacco (69.3%) was … significantly higher than the same at initiation (44.1%).” Similar to the most recent survey of adult vapers, this indicates that older users of electronic cigarettes first used tobacco flavored e-liquids and products, and then transitioned to other flavors, which helped their cessation of combustible cigarettes. Eliminating flavors will force these individuals to vape only tobacco-flavored e-cigarettes, which would likely cause them to return to combustible cigarettes.

The findings are significant as FDA, Congress, and state and local governments attempt to limit the use of e-cigarettes and vaping devices, also known as tobacco harm reduction (THR) products. In the addition to e-cigarettes, smokeless tobacco and snus, and heat-not-burn devices make up the vast majority of THR products that effectively deliver nicotine without the harmful constituents associated with combustible cigarettes.

Numerous public health organizations including Public Health England, the Royal College of Physicians, American Cancer Society, the National Academies of Sciences, Engineering, and Medicine, and FDA have acknowledged the reduced harm of e-cigarettes and vaping devices.

Evidence also suggests these products can mitigate health care costs associated with combustible cigarettes. State Budget Solutions concluded that estimated Medicaid savings could have amounted to $48 billion in 2012 if e-cigarettes had been substituted by current Medicaid smokers. In 2017, the R Street Institute analyzed “1% of smokers [within] demographic groups permanently switching.” Applying the analysis to Medicaid recipients, the author estimated savings “will be approximately $2.8 billion per 1 percent of [Medicaid] enrollees” over the next 25 years.

In addition to FDA, Congress is proposing legislation that would restrict flavors in e-cigarettes. Some localities have enforced or are in the process of imposing bans on flavors in tobacco products—including e-cigarettes and menthol in combustible cigarettes.

It’s important that policymakers refrain from imposing restrictive regulations on flavors. Ample research indicates that flavors play a vital role in helping adults transition from harmful tobacco cigarettes to THR products.

Rather than limit the options for adults, lawmakers and regulators should promote the use of these products as they have been effective cessation devices for millions of smokers and could aid alleviating health care costs related to smoking.

The following articles provide more information about e-cigarettes and tobacco harm reduction.

Vaping, E-Cigarettes, and Public Policy Toward Alternatives to Smoking
For decades, lawmakers and regulators have used taxes, bans, and burdensome regulations as part of their attempt to reduce the negative health effects of smoking. Recently, some have sought to extend those policies to electronic cigarettes. This booklet from The Heartland Institute urges policymakers to re-think that tax-and-regulate strategy. Policymakers should be mindful of the extensive research that supports tobacco harm reduction and understand bans, excessive regulations, and high taxes on e-cigarettes often encourage smokers to continue using more-harmful traditional cigarette products.

Research & Commentary: Study Finds E-Cigarettes Would Prevent 6.6 Million Premature Deaths–commentary-study-finds-e-cigarettes-would-prevent-66-million-premature-deaths
In this Research & Commentary, Heartland Institute State Government Relations Manager Lindsey Stroud examines an October 2017 Tobacco Control study that found electronic nicotine delivery systems (ENDS) might help extend life for millions of people. The authors of the study found there was an estimated 6.6 million fewer deaths and more than 86 million fewer-life-years lost over a ten year period because of ENDS products. Stroud concludes the use of ENDS could also help improve the budgets of numerous state programs, including Medicaid.

Research & Commentary: Public Health Officials Urge Use of Electronic Nicotine Delivery Systems
In this Research & Commentary, Heartland Institute State Government Relations Manager Lindsey Stroud notes the importance of NHS Health Scotland’s joint statement encouraging the use of electronic nicotine delivery systems (ENDS) as an alternative to tobacco products. NHS Health Scotland, Public Health England, and other groups have found ENDS are 95 percent less harmful than tobacco cigarettes.

E-Cigarette Primer for State and Local Lawmakers
Joel Nitzkin provides evidence e-cigarettes work as a tobacco harm reduction modality and reviews the arguments against them. He closes with recommendations for actions state and local lawmakers should and should not consider regarding tobacco harm reduction and e-cigarettes. 

Research & Commentary: New CDC Report Finds Vaping Helps Smokers Quit
A new report released by the Centers for Disease Control and Prevention (CDC) found only 0.4 percent of the people who had never smoked tobacco in a CDC study group are current vapers, which the report defines as using a vaping device either every day or some days. The CDC report, the first of its kind, estimates e-cigarette use among U.S. adults using a nationally representative household survey. The report’s findings claim only 3.4 of adults who have never smoked have tried an e-cigarette; 12.6 percent of Americans have tried an e-cigarette; and fewer than 4 percent of the U.S. population are regular e-cigarette users.

E-Cigarettes Poised to Save Medicaid Billions
In a new report from State Budget Solutions, J. Scott Moody finds e-cigarette use could create significant savings for state governments, especially in their Medicaid programs: “As shown in this study, the potential savings to Medicaid significantly exceeds [sic] the state revenue raised from the cigarette excise tax and tobacco settlement payments by 87%. As such, the rational policy decision is to adopt a non-interventionist stance toward the evolution and adoption of the e-cig until hard evidence proves otherwise.”

Research & Commentary: Study Reports Health Benefits from E-cigarette Use
In June 2016, the British Medical Journal published a study that examined electronic cigarette use after 24 months. Finding a 40 percent disparity between smokers who used e-cigarettes to quit smoking and smokers who did not use e-cigarettes, the authors found, “[E]-cigarette use alone might support tobacco quitters remaining abstinent from smoking.” In this Research & Commentary, Government Relations Coordinator Lindsey Stroud argues the growing body of evidence suggests the Food and Drug Administration may have been too hasty in its May 2016 decision to regulate e-cigarettes as tobacco products.

Nicotine without smoke: Tobacco harm reduction
This report aims to provide a fresh update on the use of harm reduction in tobacco smoking, in relation to all non-tobacco nicotine products but particularly e-cigarettes. It concludes that, for all the potential risks involved, harm reduction has huge potential to prevent death and disability from tobacco use, and to hasten our progress to a tobacco-free society. 


Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this and other topics, visit the Budget & Tax News website, The Heartland Institute’s website, our Consumer Freedom Lounge,and PolicyBot, Heartland’s free online research database.

Whether sending an expert to your state to testify or brief your caucus, hosting an event in your state, or simply sending you further information on the topic, Heartland can assist you. If you have any questions or comments, contact Heartland Institute Director of Government Relations John Nothdurft at [email protected] or 312/377-4000.