A new study provides the context that dismantles media and vape industry spin of a JAMA report widely claimed to indicate against vape flavor bans

by Clark Miller

Published August 13, 2021

Google search lit up a bit recently when a descriptive  “before and after” study published in the Journal of the American Medical Association (JAMA) described an association between ban of flavored vape and tobacco products in a locale and increased risk of initiation of cigarette smoking by youth compared to other locales with no ban.

As described online at Futurity

When voters in the city overwhelmingly approved the ballot measure, which included menthol cigarettes and flavored vape liquids, public health advocates celebrated. After all, tobacco use poses a significant threat to public health and health equity, and flavors are particularly attractive to youth.

But the new study, published in JAMA Pediatrics, suggests that law may have had the opposite effect. The findings, which compared teen cigarette use in San Francisco’s school district to trends in districts without the ban, held true even when adjusting for individual demographics and other tobacco policies.

Researchers believe the study is the first to assess how complete flavor bans affect youth smoking habits. “These findings suggest a need for caution,” says study author Abigail Friedman, an assistant professor of health policy at the Yale School of Pubic Health.

There is little reason to doubt or dismiss the likelihood that the observed changes in fact do represent shifts in behaviors of the youth surveyed to initiate smoking of tobacco cigarettes after flavored vape nicotine preparations and menthol flavored tobacco were no longer available to them.

Whether that indicates against flavor bans or attempts to address the appeal of flavored vape products as a way to reduce the epidemic levels of increased use of vape devices by youth to administer nicotine is another question entirely. And it points to the predictable distortions and risk of error in interpreting research reports and evidence posed not only by limiting factors in experimental and statistical design and analysis, but in the importance of 1) interpretation of results through lenses of broader related context and 2) replication of studies to gain confidence against undetected and uncontrolled distortions in a single study due to unidentified confounding factors, researcher bias, journal and reviewer bias, other factors.

Both apply in the case of this widely shared and promoted report that appeared to consistently be presented as having the power of a more rigorous scientific study and as warning against attempts to restrict use of or appeal of vaping to youth, implicitly grounded in the calculus of every vaping youth being protected against arguably additional health threats accruing from use of tobacco cigarettes as alternative.

The youth surveyed who transitioned to use of tobacco by smoking of cigarettes had already become “dependent” or in any case compelled to regularly administer the addictive substance nicotine – by use of the astoundingly popular and appealing vape devices driving a youth vape epidemic, and by the appeal of high-nicotine liquid preparations for vaping that are flavored. Those factors contributed to an astounding increase in youth vapers over recent years, “USA-based National Youth Tobacco Surveys reported that current e-cigarette use among high-school students, increased from 1.5% in 2011 to 20.8% in 2018”.

The critical and missing context

bearing on meaning and import of the JAMA “Research Letter” includes that astounding, epidemic-proportion youth vaping trend as well as consistent evidence that for previously never-smoking youth drawn to vaping by the social appeal, peer status value, and social and psychological draw of flavors to experiment with and continuously generate new trends, new ways to belong or be a trend-setter – vaping is a gateway for increased risk of beginning use of tobacco smoking in cigarettes.

That’s the finding in this recently published study.

As summarized by the author –

study published today in BMC Public Health demonstrates a potentially harmful relationship between adolescents using e-cigarettes who then go on to smoke tobacco cigarettes. This behavior may undermine hard-won progress in tobacco control that have been largely delivered through preventing smoking initiation in youth. Author of the study, Jean Long, talks more about the research in this blog.

. . . 

In 2013, the Tobacco Policy Review Group published Tobacco Free Ireland, a report which set a target for Ireland to reduce smoking prevalence to less than 5% by 2025. The report identified tobacco-related harm reduction as a key issue for consideration. Since e-cigarettes’ launch in the European Union (EU) in 2006 and in the United States of America (USA) in 2007, research on their potential benefits in terms of tobacco-related harm reduction, and on the public health harms of e-cigarettes, has grown. The systematic evidence review reported in this piece outlines what is known to date about using e-cigarette and initiation of smoking tobacco cigarettes among teenagers. There are two sister reviews: the first maps the harms and benefits of e-cigarettes [McCarthy 2020] and the second presents a systematic review of e-cigarettes role in smoking cessation [Quigley 2020]. These reviews are one of the inputs to the Irish governments policy and clinical guidelines on e-cigarettes.

Our systematic review published in BMC Public Health found that e-cigarette use among teenagers in Europe and North America was associated with starting tobacco cigarette smoking. Based on nine primary studies’ adjusted odds ratios, our meta-analysis calculated a three to six times higher odds of starting tobacco cigarette smoking for teenagers who had ever used e-cigarettes at baseline. These findings identify an important health-related harm and are supported by four other systematic reviews. [Soneji 2017; Glasser 2019; Khouja 2019; Aladeokin and Haighton 2019] Three of these reviews were among young adults [Soneji 2017; Glasser 2019; Khouja 2019] and one was in teenagers living in the UK [Aladeokin and Haighton 2019]. These findings are important because the prevalence of e-cigarette use is increasing in Europe and North America. For example, the prevalence of e-cigarette use among teenagers in the USA increased from 1.5% in 2011 to 20.8% in 2018 [Cullen 2018] and in Ireland ever use is 22% [Költő 2020]. Additionally, there is a danger that society will not be able to protect achievements in declining tobacco cigarette initiation among teenagers.

So, in an emergent youth cultural trend of a new, cool behavior increasingly adopted by peers and chosen by celebrities, supporting autonomy and individuation with flavor choices, and culturally increasingly branded as a safe or healthy alternative to cigarette use, kids who had never used nicotine before by inhalation did so using e-cigarettes and the appealing flavors. And became dependent on nicotine. In epidemic numbers. And the research predicts that a significant share of them will likely go on to use tobacco by smoking, the “gateway” effect that proponents of vaping as a form of “harm reduction” didn’t count on. Didn’t think of.

And are in denial about. Because depending on the size of that effect, the public health rationale is strong and compelling for action that prevents use of flavors, psychologically manipulative advertising including covert advertising on social media, and other ploys to recruit youth to become dependent on nicotine delivered in electronic devices. That prevention most likely would have helped avoid the youth epidemic of nicotine abuse, delivered in e-cigarettes. And without that epidemic, fueled by those types of shrewd, manipulative advertising aimed at young people, there would not have been a large population of kids who had developed dependence on nicotine and the positive social and esteem gains related to using the socially normed vape devices and exploring flavors as a social connectivity. In the failure to recognize early in the youth vaping epidemic those appeal factors and to address them, including by flavor bans, public health regulators generated a large population of kids who, of course, are predicted to take up an alternative nicotine delivery behavior once their preferred forms are unavailable to them. It’s difficult to stop compulsive nicotine use, as difficult for a teen as stopping any behaviors that are perceived as increasing their success in being experienced by peers as desirable, attractive, interesting, and desired in their social circle.

The meaningful public heath questions are about how the importance of flavors and marketing by vape industry profit makers to choices by young people could have and should have been controlled to prevent harm to children who would be influenced to start using vapes and develop nicotine dependence. It was that nicotine dependence that drove any switching to cigarette use that may be represented in the JAMA report.

But that primary, preventative line of thought about pediatric addiction and harm was not being pursued by regulators or the editors at JAMA when vaping by youth who would become nicotine dependent was rapidly expanding. Instead, JAMA was celebrating at that time an FDA plan to promote vaping as harm reduction based on conclusions from a very limited data set that would soon be falsified by longstanding and increasing evidence that essentially predicted the youth vaping epidemic.

From a previous post:

Accumulating evidence points to runaway rates of “vaping” of nicotine among youth, now characterized as posing unknown risks and as an epidemic warranting investigation by the Food and Drug Administration (FDA) who last year announced plans for promotion of e-cigarettes as harm reduction, a strategy endorsed in the nation’s leading medical journalAnd is increasing rates of youth who will smoke tobacco. 


Endorsement of the FDA plan in the Journal of the American Medical Association (JAMA) cited a small downward shift in vaping by youth over just one year- 2016. But as described in new reports in the online news source Vox and increasingly elsewhere, more recent data point to booming use of e-cigarettes among youth, that use increasing likelihood of young people starting to smoke (tobacco) cigarettes.

. . .

the FDA/Medical Industry plan and endorsement for vaping as effective harm reduction relied on an irresponsibly limited data base; was not grounded in a research base adequate to support confidence in vaping behavior as reducing use of tobacco overall or confidence in vaping health effects as significantly benign compared to those for tobacco; and ignored the direct links among nicotine, risk of onset of type 2 diabetes, and increasing rates of diabetes among youth.

Nicotine, an addictive substance, may be delivered in vape devices in concentrations as high or higher than in regular cigarettes. The delivery and behavioral nature of vaping and smoking predict higher potential for conditioned psychological dependence. To a greater degree than other substances, the bioactive delivery of nicotine vaped or smoked, and the comforting behavioral ritual, are repeated many times each day, with each inhalation, up to hundreds of times each day. That is, the cycle of felt need or compulsion to deliver the mood-altering substance, its delivery by inhalation, and the rewarding sensory/mood alteration are repeated many to hundreds of times each day. That’s a lot of positive reinforcement of the behavior.

Like the FDA, JAMA was too busy promoting vaping to be concerned about evidence for its gateway effects or the signs of how its marketing as a new trend was affecting vulnerable youth. Or the evidence for risk of worsening of a youth and adult diabetes epidemic by the known effects of nicotine, whether administered by tobacco smoked in cigarettes of liquids in e-cigarettes.

That’s why replication is so important, in this case illustrated by the publication of an observational report that was interpreted without context and published in a journal – JAMA, the nation’s premier medical journal – that a few years ago was promoting vaping as harm reduction while a youth vaping epidemic had begun and with evidence of it worsening. That promotion would have been powerfully influential with medical providers, who routinely advise child and adult patients on use of tobacco products and health-related behaviors including vaping.

It’s impossible to ignore the parallels

with another of multiple public health threats – the opioid crisis.

  • An observational study without replication or contextualization is interpreted and popularized as providing significant evidence for public health policy against available relevant evidence invalidating the conclusion.
  • Social media and/or corporate media popularize the unwarranted interpretation and conclusions to support dominant medical model interventions (medication of chronic pain, harm reduction by substitution for problem substance use) for the non-medical problems.
  • In the face of associated public health epidemics, public health policy is driven by medical model responses that continue to dispense and/or support use of addictive, harmful substances as “treatment” for problem substance use.

The medical rationale is the same – we must provide and continue to provide the substitute substance of abuse in a form we assert is less harmful and dangerous, in order to prevent use of more harmful forms of the substance. We know how that’s worked out for problem opioid use and the medical fix of opioid substitution treatment (OST, or MAT).

There may be a pattern.

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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