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Hoichang Noh

ECO 321

Dr. Helen Schneider

6 Dec 2021

The Effect of Flavored E-Cigarettes on Public Health in US

Introduction

Thousands of United States citizens have been killed by just one habitual behavior,

cigarette smoking. Cigarette smoking is considered one of the most fatal habitual behaviors that

threaten public health in the United States. Recently, the death of one out of five individuals can

be attributed to cigarette smoking in the United States (Gee. et al.,). Due to the rising public

death rate of cigarette smoking, billions of dollars have been invested and many professionals

working for public health such as clinicians, policymakers, and public health professionals are

dedicated to limit future tobacco use by various mechanisms (Gee. et al.,). As a result, the

declines in national combustible tobacco smoking rates could finally be seen from 1965 to 2000

by raising tobacco taxes, mass media campaigns, nicotine replacement therapies, prescription

drugs, and education on the dangers of smoking (Gee. et al.,).

The advent of e-cigarette ruined these efforts and led a new generation of youths to

become addicted to nicotine and tobacco products (Gee. et al.,). Thousands of Americans still die

annually due to nicotine addiction, which has a direct effect on death caused by tobacco use

(Gee. et al.,). According to AJPH (A publication of the American Public Health Association),

preventing youth exposure from smoking is the most important step to stop this tragedy because

nearly 90% of adults who smoke cigarettes daily were exposed to smoking by 19 years old and

started cigarettes by 26 years old (Gee, et ap.,). For example, an experiment conducted by the
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state of Louisiana stated that it is true that tobacco smoking rates of youths is showing a

downward trend for the past years, but an abrupt increase in e-cigarette use can be seen among

high school students with more than 45% of high school youths reporting having used an e-

cigarette in Louisiana (Gee. et al.,). Likewise, the high use of e-cigarettes among youth was

driven by “corporate marketing practices” that targeted youths with appealing flavors,

advertisements, and the introduction of new handy e-cigarette such as “Juul” in the United States

(Teresa W. Wang). To be more specific, the high rate of e-cigarette use is shown not only in

Louisiana, but the entire country is experiencing a downward trend, but the whole US is also

experiencing a downward tobacco smoking rate and upward e-cigarette smoking rate. As a

response to this changing trend, the state government, the local government, and the US Food

and Drug Administration (FDA) banned flavored e-cigarettes sales without “restricting open

system of custom mixed and vape shop e-liquids in January 2020” (Abigail S. Friedman).

Importance of the study

This rising public health challenge changed the federal legal age to purchase tobacco

change from 18 to 21 years in 2019 (only 33 states passed this legislation) and the Food and

Drug Administration took a step to prioritize enforcement against the unauthorized flavored

cigarette products in January 2020 and July 2020 by sending warning messages to companies or

penalizing companies for high rates of youth uptake (Teresa W. Wang). At this point, market

failure can be introduced due to market distortion that the youth demand more e-cigarettes, while

FDA banned flavored e-liquids. E-cigarette indeed produces both positive and negative

externalities. E-cigarettes not only can benefit the third party by being a substitute for

combustible tobacco, but they can also harm the environment with e-cigarette plastic waste, and
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harm public health by alluring non-smokers to start smoking. However, in this aspect, it can be

concluded that e-cigarette produces negative externalities because e-cigarette, regardless of being

a substitute for combustible tobacco, still causes a significant negative impact on public health.

Overall, public health in the entire United States is harmed due to the high rate of smoking with

irresistible nicotine addiction. While the rate of combustible tobacco uses declined with various

mechanisms implemented by professionals such as raising the tax, using mass media, and

education, the rate of youth using e-cigarettes has increased because of its appealing flavors and

devices targeted to the youth by companies. Since preventing the youth from exposure to

smoking is the best solution for this public issue, it is imperative to analyze the effects of

smoking flavored e-cigarettes in youth in greater detail on the entire public health in the United

States.

Literature Review

E-cigarette use has drawn considerable public attention as being an alternative to

smoking tobacco and its unknown possible effects on public health and indoor air quality

promote anxiety into society. An experiment was implemented to compare the effects of e-

cigarette use to standard tobacco cigarettes. For the method of the experiment, “four different

high nicotine e-liquids were vaporized in two sets of experiments by generic 2-piece e-cigarettes

to collect emissions and assess indoor air concentrations of standard tobacco smoke for

comparison” (Taylor & Francis). As a result, the experiment found out that e-cigarettes produce

a very small amount of exposure relative to standard tobacco cigarettes and the study further

indicates that the effects of e-cigarette emissions have no apparent risk to human health based on

the analysis (Taylor & Francis).

As e-cigarette use has become popular among the youth, the impact of e-cigarette use on

oral health is also unknown whereas the impact of conventional smoking on oral health is well

recognized by the public (Yang, Irene, et al). A study was conducted to inform the public about

the impact of e-cigarette on oral health with evidence through three electronic databases:

PubMed, Web of Science, and Embase (Yang, Irene, et al). This study mainly focuses on the oral

effects such as mouth effects, throat effects, and dental effects, etc. (Yang, Irene, et al). As a

result, e-cigarette users had minor and temporary symptoms on the mouth and throat and

conventional users who switched to e-cigarettes experienced mitigation of these symptoms

(Yang, Irene, et al). Meanwhile, e-cigarette exposure increased the risk for deteriorating

periodontal (teeth and gums), dental, and gingival health as well as the changes to the oral

microbiome with components of cytotoxic, genotoxic, and carcinogenic properties (Yang, Irene,

et al). Moreover, extensive dental damage from e-cigarette explosions was reported in case

reports (Yang, Irene, et al). Based on the study, it is true that switching to e-cigarettes from

conventional smoking can mitigate several symptoms to some extent, but several deteriorating

symptoms are also driven by e-cigarette uses.

Additionally, a study was conducted to see whether taxes on e-cigarettes and raising the

tobacco legal purchasing age to 21 years (T21) with state-level e-cigarette inclusive smoke-free

policies (ESF) affect recent upward trends in youth e-cigarette use (Kelvin Choi). The study,

comparing participants from 34 different US states with ESF policies, taxes, and T21 policies,

tells us that the state-level ESF and T21 have effects on limiting the growth of youth e-cigarette

use, despite an overall national increase (Kelvin Choi). Especially, higher e-cigarette tax rates

would be needed to effectively reduce youth e-cigarette use (Kelvin Choi).

Analysis

Theoretical – Negative Consumption Externality Model

The negative consumption externality model can be used to show the possible outcomes

of the federal ban on the flavored e-cigarette sale to oppress the uprising trend of the youth e-

cigarette smoking rate in the United States. Negative externality in this case also shows that the

flavored e-cigarette consumed adversely affects the third party such as the effects of e-cigarette

plastic waste on the environment.

The graph above represents the market economy before the federal ban on flavored e-

cigarette sales in the United States. Private marginal benefit (PMB) shows that individuals

benefit from consuming flavored e-cigarette and social marginal benefit (SMB) indicates the

total marginal utility of the flavored e-cigarette to the public (PMB + external benefits). This is
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shown in the graph with an output of flavored e-cigarette on the x-axis, price per flavored e-

cigarette pod (e-liquid) on the y-axis, and the market quantity of flavored e-cigarette represented

by Qm on the x-axis with the market price Pm.

Now, the federal ban on flavored e-cigarette is implemented in the United States. Private

marginal cost (PMC), the cost to produce flavored e-cigarettes such as labor and equipment, and

supply curve shifting left due to the federal ban on the flavored e-cigarette (S=PMC=SMC)

become vertical axis with zero quantity at any price as indicated with red line on the y axis.

Moreover, the social marginal benefit with new efficient quantity is created because flavored e-

cigarettes produce negative externalities such as plastic waste from e-cigarettes. Thus, the social

marginal benefit is located below the private marginal benefit whereas the supply of flavored e-

cigarettes comes with zero quantity. As a result, the deadweight loss, which can also be called

economic efficiency loss, is created (the shaded triangle on the graph). Lastly, as the

S=PMC=SMC curve shifts left to become vertical axis, we can see that the new quantity created

by the federal ban on flavored e-cigarettes is far below the efficient quantity of flavored e-

cigarettes.

Empirical – Time Series Analysis

The effects of the federal ban on flavored e-cigarettes in the United States can be best

addressed using time series analysis. As the name indicates, time series analysis, in this case,

requires data collected over time at consistent intervals to see the relationship between the

federal ban on flavored e-cigarettes and the susceptibility of youth smoking e-cigarettes.

To estimate the effects of a federal ban on flavored e-cigarettes along with the

susceptibility of youth smoking e-cigarettes, this analysis will not only focus on investigating

high school students and middle school students by a national survey to see the frequency of
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vaping and whether they are current and previous users who have used e-cigarette or non-

smokers but also focus on the two different timelines by comparing the effects of after and

before the federal ban on a flavored e-cigarette. This investigation will lead to show the factual

changes of their smoking status (smoking or non-smoking) along with the federal policy.

Location, frequency of vaping, and status of smoking play an important role in

implementing the time series analysis. The location represents similar trends in income, race,

education, and spending. The frequency of vaping trends and the status of smoking along with

the federal ban help us see the effects of the federal policy. Moreover, comparing youths such as

middle school students and high school students in similar districts along with the two different

timelines will lead the results unbiased. However, since the investigation is focusing on the

effects of flavored e-cigarettes in the United States, data from the 2020 National Youth Tobacco

Survey (NYTS) may show the youth smoking trends in the entire US (Wang, et al. 2020). NYTS

found out that youth e-cigarette use rose between 2017 and 2018 by analyzing vaping patterns

(Allison M Glasser) and decreased during 2019 and 2020 with “overall prevalence, frequent use,

and flavored e-cigarette use remained high” (Wang TW). Likewise, conducting a survey targeted

to high school students and middle school students with location, frequency of vaping or

smoking, and status of smoking will help collect data over time at consistent intervals and see the

effects of a federal ban on flavored e-cigarette whether it increases or decreases the youth vaping

or smoking rate in the United States.

Conclusion

The federal ban on flavored e-cigarettes that intended to reduce youth e-cigarette use is

necessary for our society because preventing youth exposure to smoking or vaping is the best

solution to stop the rising public death rate and the previously increasing youth vaping rate by

appealing advertisements, flavors, and a rising trend among young adults. Theoretically, the

federal ban on flavored e-cigarettes with the rising perception of e-cigarette risks leads to social

marginal benefit located below the private marginal benefit with zero quantity at any price.

Empirically, time series analysis can be used for federal policy. By conducting a survey targeted

to middle school students and high school students along with two different timelines (before and

after the federal ban) based on location, frequency of vaping, and status of smoking, the effect of

the federal ban on flavored e-cigarettes in reducing youth smoking rate in the United States can

be investigated. Lastly, several studies were conducted to test the hazard of e-cigarette use such

as comparing e-cigarette emissions and indoor air concentrations of standard tobacco smoke,

analyzing participants from 34 different US states with ESF policies, taxes, and T21 policies, and

studying the impact of e-cigarette use on oral health. The key conclusion that was found from

these studies is that it is true that e-cigarette use substituting for conventional smoking mitigates

fatal symptoms to some extent and eliminates secondhand effects, but it also has a high

possibility of driving new concerns including e-cigarette explosions and toxic chemical

components in e-liquids.
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