Vaping Restrictions: Is Priority to the Young Justified?

Abstract

The vast majority of smokers become dependent on nicotine in youth. Preventing dependence has therefore been crucial to the recent decline in youth smoking. The advent of vaping creates an opportunity for harm reduction to existing smokers (mostly adults) but simultaneously also undermines prevention efforts by becoming a new vehicle for young people to become dependent on nicotine, creating an ethical dilemma. Restrictions to access to some vaping products enacted in response to the increase in vaping among youth observed in the United States since 2018 have arguably prioritized prevention of new cases of dependence—protecting the young—over harm reduction to already dependent adults. Can this prioritization of the young be justified? This article surveys the main bioethical arguments for prioritizing giving health benefits to the young and finds that none can justify prioritizing dependence prevention over harm reduction: any reasons for prioritizing the current cohort of young people at risk from vaping will equally apply to current adult smokers, who are overwhelmingly likely to have become nicotine-dependent in their own youth. Public health authorities’ current tendency to prioritize the young, therefore, does not seem to be ethically justified.

Implications

This article argues that commonsense reasons for prioritizing the young do not apply to the ethical dilemma surrounding restricting access to vaping products.

Introduction

At least since the 1994 reports by the Surgeon General, Preventing Tobacco Use Among Young People, and by Institute of Medicine (IOM), Growing Up Tobacco Free, the US tobacco control field has oriented its efforts to rid the population of smoking and its resulting harms toward children and young people. Broadly speaking, the overarching aim was to keep young people away from nicotine, so as to lower the numbers of new nicotine-dependent persons that would replenish the ranks of smokers.¹ As a result of this focus on prevention during childhood and youth, tobacco use was referred to as a “pediatric disease” by the Food and Drug Administration (FDA)² and the American Academy of Pediatrics (AAP).³ The reason for a primary focus on the young was clear: the vast majority of smokers start smoking before the age of 18, and practically all start smoking before the age of 25.¹ Smoking in adolescence is an important predictor of adult smoking, and intensity of smoking in adolescence is inversely related to rates of cessation in adulthood.⁴ For those already nicotine dependent, and therefore facing high risks of illness or premature death due to smoking, cessation strategies could be pursued alongside the push for prevention.

The advent of the electronic cigarette (by which I mean electrical devices for delivery of nicotine via vapor) changed this picture profoundly. On the one hand, vaping is a potentially promising tool for cessation or harm reduction. A recent report by the National Academies of Sciences, Engineering and Medicine finds “conclusive evidence” that completely switching from combustible to electronic cigarettes “reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco” and “substantive evidence” that switching from combustible to electronic cigarettes reduces short-term harms to health.⁵ Public Health England estimates that “vaping is at least 95% less harmful than smoking.”  ⁶

On the other hand, the United States in particular saw a sharp increase in vaping by young people. In 2018, the FDA changed its tone considerably on this issue, going from referring to electronic cigarettes as a potentially helpful cessation tool to expressing worry over an “epidemic” of vaping by young people⁷ and taking action against electronic cigarette manufacturers and retailers.⁸ Although almost all US states had already restricted access to any nicotine product to those over 18 or 21, some localities reacted to the youth vaping spike by proposing or enacting bans or further restrictions on access to vaping products, flavored vaping products, or some kinds of flavored vaping products. An outbreak of lung injuries, affecting 1479 people and killing 33 as of October 15, 2019,⁹ apparently linked to illicit THC vaping products, led to further restrictions in states including Montana, Michigan, New York, Rhode Island, Oregon, and Washington.

The 2018 and 2019 restrictions took several forms, from general bans on sales of all vaping products (as adopted temporarily by Boston) to bans on all flavors other than tobacco or bans on only some flavors considered most appealing to youth. Such restrictions, to varying degrees, reduce the availability and attractiveness of vaping products both to youth and to current smokers—flavors other than tobacco, for example, appeal both to the young and to current smokers.^10–12 Given that, in most cases, no corresponding restrictions were placed on combustible cigarettes, the new restrictions on vaping reduced the attractiveness and accessibility of vaping products relatively to the attractiveness and accessibility of combustible cigarettes. Compared to the state of affairs before the recent restrictions, then, these restrictions reduce risks to youth (by making it more difficult and less appealing for youth to take up vaping), at the cost of reducing the chances of smokers to benefit from switching (by making vaping less accessible and less attractive).

The question then arises: in the face of this trade-off, are there reasons for giving priority to protecting the young against nicotine addiction over protecting smokers from the morbidity and mortality caused by smoking?

Before electronic cigarettes, measures taken in order to benefit young people by lowering their risk of becoming smokers (such as minimum legal age of access, restrictions on advertising and on smoking in public places, and denormalization strategies) were not in direct contradiction with measures taken to benefit smokers through promotion of smoking cessation: public smoking bans and denormalization not only protect the young but also give smokers additional reasons and incentives to attempt cessation. The fact that youth is the time when smokers become addicted suffices as justification for pursuing policies that focus on the young, as there was no loss of benefits to other groups that needed to be outweighed. Likewise, restrictions on vaping that target young nonsmokers precisely (eg, age restrictions on purchases of all nicotine products, or bans on particular vape flavors that appeal to young never-smokers but do not meaningfully facilitate smokers’ switching) benefit young people without decreasing smokers’ prospects of harm reduction, and therefore do not pose this trade-off.

However, restrictions of the kind being discussed here seem likely to affect both groups to some extent: restricting access to vaping products to reduce risk of harm to the young comes at the cost of foregoing potential harm reduction benefits to adult smokers, particularly when combustible cigarettes are not made commensurately less accessible or less attractive.

Restrictions on sales of combustible cigarettes, significant cost increases, or other measures making cigarettes less accessible or less attractive—such as bans on flavored cigarettes, which New Jersey and Massachusetts have enacted—could dramatically change or eliminate the trade-offs under discussion, by pushing smokers toward vaping (or other cessation aids) in spite of difficulties in access to or reduced attractiveness of vaping products. However, such measures were not always brought into discussion alongside the restrictions on vaping products.

Reasons to Prioritize the Young

Effectiveness, Equity, and “Fair Innings”

Research eliciting societal views on how to prioritize health care resources, in general¹³ or between age groups,^14,15 often identifies concerns for effectiveness (maximization of benefits), equitable distribution of benefits, and responsiveness to need. In the case at hand, responsiveness to need (the “rule of rescue”) would arguably favor prioritizing harm reduction to current smokers, who are facing the greatest and most imminent harms. Maximization and equitable distribution of benefits, however, tend to favor prioritizing the young.

The most intuitive reason to prefer policies that favor younger over older age groups is straightforward outcomes maximization: prioritizing young people is likely to create more benefit, overall, since the young have longer to live. Prioritizing younger patients to receive a scarce life-saving drug, for example, would in aggregate save more life-years than prioritizing older patients.

In the case of tobacco, this rationale does not apply. The bulk of the disease burden caused by smoking happens later in life, not at the young ages when nicotine users become dependent: smokers die earlier (according to the CDC, smokers’ life expectancy is at least 10 years shorter than that of nonsmokers¹⁶), and most diseases strongly linked to smoking, such as cardiovascular diseases, COPD, and several types of cancer, tend to not affect smokers in their youth. Smoking also causes harm in youth, such as respiratory illnesses, increased inflammation, and nicotine addiction itself, which can be considered a harm to autonomy or to one’s will. Yet, the bulk of the morbidity and mortality attributable to smoking happens in adulthood (for a thorough survey of health effects of smoking at each life stage, see the IOM’s report Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products¹). Even if, counter to what the evidence suggests so far, vaping was nearly as harmful as smoking, we would not be saving many more life-years by focusing on the young. In the aggregate, if vaping is indeed far less harmful to heath than smoking, then it seems very likely that greater harms can be averted at the population level by reducing the harms caused by smoking than by avoiding the comparatively smaller harms caused by vaping.

A different argument for priority to the young is made by appeal to the principle of equity: the young have had fewer life-years (in the case of benefits that avert mortality) or had fewer healthy life-year equivalents (in the case of benefits that avert morbidity). It is therefore inequitable to prioritize giving even more life-years, or healthy life-years, to adults, who have already had more. A particularly well-accepted argument of this kind is the “fair innings” argument, according to which “everyone is entitled to some ‘normal’ span of health,”  ¹⁷ and equity weights are applied to the valuation of health benefits so as to highly value bringing people up to this “normal” (quality-adjusted) level of entitlement, while discounting gains above this level.

As in the maximizing argument, it is clear that these equity-based arguments do not apply to the case at hand. Ultimately, these arguments appeal to idea that a death at a young age is worse than a death at an older age—as dying young precludes living a “full” life—to justify giving priority to interventions that help younger people over interventions that help older people. Tobacco, however, generally does not kill its users at a young age. In the case of the “fair innings” argument specifically, the young are at least as likely as older smokers to attain fair innings (if vaping is roughly as harmful to health as smoking) and may be more likely to attain fair innings (if vaping does indeed reduce harm).

Responsibility and Vulnerability

Whether or not personal responsibility has a role to play in health care policy is a hotly contested question, as are the conditions under which a person can or should be held responsible for their voluntary choices and the health effects of these choices.¹⁸ If we were to accept that adult smokers and young vapers should be held responsible for their choices, then this might provide a reason for prioritizing the young: young people are more prone to taking risks,¹⁹ possibly due to greater susceptibility to peer influence,²⁰ and therefore it is generally accepted that children and adolescents do not have the same capacity as adults to voluntarily consent to risk. The young should therefore not be held responsible, or not be held responsible to the same extent, for bad outcomes resulting from their choices.

For the question at hand, however, it does not ultimately make a difference whether or not we believe that personal responsibility should matter in deciding what to prioritize and whether or not we believe the young should be held responsible to a lesser extent than adults: personal responsibility does not distinguish a current smoker, who almost certainly started smoking in youth, from a current young person who will become dependent on nicotine if we fail at prevention. Either current adult smokers and young people who become dependent on nicotine via vaping are both responsible for the harms they may suffer as a result of their nicotine addiction, or neither is responsible.

Other sorts of arguments could be made for prioritizing the young over adults in general, which are hinted at by the word “pediatric,” as used by the FDA and the AAP to describe smoking. The thought that a condition is “pediatric” may trigger an intuitive sense that conditions affecting children deserve priority over similar or equivalent conditions affecting adults, that adults ought to allow children and young people who are suffering harm to be helped first. This intuition may stem from the greater helplessness or vulnerability of the young, and their lower ability to understand and cope with pain and suffering. But that is not the sense in which smoking is a “pediatric” condition, as most of the health harms resulting from smoking happen later in life and not at the time of smoking uptake, during youth. The point in life at which these harms will happen is roughly the same for current adolescents and young adults, and current adult smokers. In tobacco use, there is no distinction between pediatric cases and adult cases.

A more tobacco-specific version of the vulnerability argument appeals to the greater susceptibility of the young to social and environmental influences that can push them toward tobacco, which have been exploited by the tobacco industry to maintain demand for its products.²¹ Again, current smokers also started smoking in youth and are therefore suffering later-in-life harm due to the same vulnerabilities. If these vulnerabilities are a reason to prioritize the young, as in the case of responsibility, then these reasons also apply to the adolescents of the past (current adult smokers). If we owe protections against nicotine addiction to the young of today, then current smokers were owed the same protections due to their own vulnerability in their youth, but the fact that larger shares of young people used to become addicted in the past shows that protections in the past were considerably less effective.

Rather than give us reason to prioritize the young, the argument from exploitation of vulnerabilities by the tobacco industry could even, arguably, give us reason to prioritize current adult smokers. Current adult smokers, in their own youth, had similar vulnerabilities to the young of today, but were granted relatively weaker protections then and are now facing greater and more imminent harms (compared with the smaller harms expected to affect current young vapers when they reach adulthood). It is not obvious, however, that we have reasons to prioritize current smokers in order to mitigate this harm: being owed (some degree of) protection against a risk does not entail being owed a guarantee that the risk will not eventuate, and it seems implausible to consider improvements in public health unfair to the generations who lived before these improvements. Even if it does not give us reason to prioritize adult smokers, this argument also fails to justify priority to the young.

Limitations

Throughout the argument here, I discuss only the trade-off between the increase in risk to the young created by vaping and the decrease in risk to current adult smokers. This leaves out the decrease in risk to those young people who would have become smokers but become vapers instead. Not all young people face a net increase in risk of harm due to the availability of vaping. Intragenerationally, between groups of young people, the availability of vaping represents a redistribution of risk from those who would have smoked to those who would not have smoked in the absence of vaping: some of the smaller number of young people who would have smoked cigarettes if vaping did not exist will most likely vape instead, with some possibly later transitioning to cigarettes—as a group, their total expected harm decreases due to the availability and popularity of vaping. On the other hand, some of the young who would not have used any form of nicotine if it were not for the vaping trend will now become addicted via vaping, and possibly later transition to cigarettes. The latter group, therefore, faces higher risks than they would have faced in the absence of vaping (on the justifiability of redistributing risk, see Eyal in this issue²²).

Due to the unavailability of long-term evidence on the health effects of vaping, I have at some points in this argument implicitly assumed that the profile of harms caused by vaping early versus late in life is similar to that of smoking. In light of the existing estimates of the relative harms of vaping as compared with combustible cigarettes, this is unlikely to be true, and we should expect the harms of vaping to be lower throughout the lifecourse. This assumption should therefore be taken as an unlikely worst-case limit scenario for vaping. If indeed vaping turns out to be less harmful than smoking, the case for prioritizing the young becomes even weaker, as the averted harm to the young becomes smaller in relation to the harm to current smokers that is not averted due to lower availability and/or attractiveness of vaping in relation to combustible cigarettes.

Arguably, another limitation of the argument presented here is that the argument is based on comparisons of the harms of vaping and of smoking that measure harm in terms of morbidity and mortality only, leaving out the harms to autonomy, or harms to the will, caused by dependence itself. In this simplification, I follow the IOM and NAS reports cited above, and most of the existing evidence on the harms of vaping and smoking. For now, there is no available data on the comparative effects on autonomy of vaping versus smoking, or an accepted way of trading off these harms to autonomy against morbidity and mortality, so the simplification is necessary. Comparing the harms of vaping and the harms of smoking in a way that incorporates harm to autonomy would require the monumental task of measuring the disvalue of diminished autonomy due to dependence, or the disvalue of its effects, and creating a summary measure of harm that incorporates morbidity, mortality, and addiction.

Conclusion

The advent of electronic cigarettes introduced a trade-off between protecting the young against nicotine addiction and reducing harm to adult smokers, which creates an ethical dilemma. Some responses by state and local authorities so far seem to prioritize protection of the young over harm reduction to adult smokers.

Ethical arguments based on maximization of life-years, equity, and “fair innings” do not justify prioritizing the young. The young people who are under increased risk due to the availability of electronic cigarettes, and who need to be protected from becoming addicted, are not at risk from dying in youth because of vaping or nicotine addiction. They will not lose a greater number of life-years to vaping than a current smoker who is now an adult but who started smoking in youth will lose due to cigarettes. These young people will not be further away from “fair innings” than a current smoker who is now an adult but who started smoking in youth.

Similarly, arguments appealing to the greater vulnerability of young people, in general or to the specific vulnerabilities that have historically been targeted by the tobacco industry, also fail to justify prioritizing the young, as current adult smokers were vulnerable in the same ways in their own youth.

Public health authorities’ current tendency to prioritize the young, therefore, does not seem to be ethically justified.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

A grant supplement from the National Institutes of Health (parent grant R01CA190444; PI: Delnevo) supported this work.

Declaration of Interests

None declared.