As a physician – one who has dedicated his career to treating lung diseases – it has become clear to me that asking a smoker to quit, gradually cut back, or instructing smokers on the use of more traditional nicotine-replacement therapies, like nicotine gum or patches, is not as simple or as effective as it sounds. Hence, the availability and acceptability of safer tobacco and nicotine products may be critical to successfully helping adult smokers move away from traditional cigarettes.
In 2017, the FDA announced in the New England Journal of Medicine that its approach to reducing the toll of disease caused by smoking would be grounded in “the continuum of risk for nicotine-containing products.” The “foundational understanding” underpinning this approach is that nicotine per se in tobacco products is “not directly responsible for the tobacco-caused cancer, lung disease, and heart disease that kill hundreds of thousands of Americans each year.”
Accordingly, the FDA authorized the marketing of more than a dozen tobacco products (snus, tobacco-heating products, and even very-low nicotine cigarettes) as modified-risk products with many containing flavors such as mint or menthol. All of these products are now on the chopping block in Maine.
A bill under consideration in Maine’s 2022 state legislative session threatens to bring both the federal and individual efforts to reduce the harms caused by cigarette smoking to a screeching halt.
LD 1550 passed out of the Joint Standing Committee on Health and Human Services with a split report: the majority report supporting passage of a complete flavor ban; the minority report supporting the flavor ban with the exception of (1) mint/menthol flavored products and (2) products authorized for marketing by the FDA through its premarket tobacco application (PMTA) process or its modified-risk tobacco product (MRTP) pathway.
The majority report on LD 1550 denies adult smokers in Maine access to a variety of safer tobacco products that may be more acceptable to them as alternatives to cigarette smoking. This is the very group of smokers at the highest risk for smoking related disease.
In the effort to provide smokers with alternatives, new technologies are promising. A study published in December 2021 in the Journal of the American Medical Association (JAMA) reported that cigarettes smokers who used e-cigarettes daily were eight times more likely to quit smoking entirely than those who did not use e-cigarettes daily – even though none of these smokers had any intention to quit smoking at the beginning of the study.
No one wants young people to smoke, vape or use tobacco products of any kind. Concerns for an increasing youth use of e-cigarettes are not supported by data collected by the CDC. Laws prohibiting the sale of these products to youth have been enacted at both the state and the federal level, and they must be enforced. The CDC data from 2019, 2020, and 2021 suggest youth use of e-cigarettes has plunged since the implementation of the federal Tobacco 21 law in December 2019: down 33 percent in 2020 and another 43 percent in 2021.
A recent example shows that a drastic, wide-reaching flavored tobacco ban may have negative, unintended consequences for Maine’s youth. Another 2021 JAMA study found that high school smoking rates in San Francisco actually increased compared to other school districts in California and nationwide after the city banned the sale of all flavored tobacco products in 2019.
While both youth and adult cigarette smoking also remain historically low nationwide, there are still more than 30 million adult smokers in the U.S. and more than 165,000 adult smokers in Maine.
The bill being considered in the 2022 legislative session discounts the FDA’s assessment of safer alternative tobacco products and today’s adult smokers require access to acceptable alternatives to cigarettes. Combined with a lack of consideration of its likely unintended consequences, this bill is not good for public health in Maine.
