Ending the sale of flavored tobacco products is the real harm reduction

Yesterday (May 9, 2022) I testified before the Colorado Senate Finance Committee supporting a proposed statewide ban on the sale of all flavored tobacco products. As usual, opponents claimed that flavored products were needed for “harm reduction.”

In listening to their testimony, I realized that for e-cigs and other tobacco products to actually reduce harm, at the very least, most smokers who use them would need to stop smoking cigarettes. In fact, on a population level e-cigarettes as consumer products do not help smokers quit smoking. Indeed, the most recent studies show that smokers who use e-cigs to quit, quit less. Without providing quitting benefit, the question of whether e-cigs are less or more toxic than a cigarette doesn’t even come up.

Of course, the opponents of the legislation minimized the impacts on kids, simply saying they didn’t think kids should use them. As I note in my testimony, kids are more than 5 times as likely to use e-cigs as adults. Virtually all kids use flavored products. This is harm enhancement, not harm reduction.

Another argument opponents use is that flavor sales bans reduce tobacco tax revenues. This is correct, because they reduce tobacco use. (That’s why the tobacco companies mobilize opposition.) But when people stop buying tobacco, they spend the money on something else, which contributes more to the local economy.

This is important, because Colorado Governor Jared Polis has said he will veto the law because he wants the tobacco tax revenue to fund early childhood education. Leaving aside the fact that Polis is effectively saying he wants to poison on set of kids to educate their younger siblings, the reality is that the flavor ban will save the state money and increase other taxes. That will make more than enough money available to keep funding early childhood education.

Here is the written testimony I submitted. There was also oral testimony and Q&A at the hearing.

RE: HB 22-1064, PROHIBIT FLAVORED TOBACCO REGULATE SYNTHETIC NICOTINE

The Fiscal Note[1] for this bill correctly notes that eliminating the sales of flavored tobacco products will reduce tobacco use by encouraging cessation and discouraging youth initiation, with an attendant reduction in tobacco tax revenues.

The Fiscal Note, however, ignores 3 positive financial impacts of the bill, including on government revenues:

• The reductions in tobacco consumption will result in rapid and substantial reductions in medical care costs (by the next year) paid by Colorado state and local governments as well as individual taxpayers and businesses.
  • This is because risk of heart attacks, strokes, lung problems and complications of pregnancy falls quickly, with cancer risks falling more slowly.
  • A 1% relative reduction in smoking is followed the next year with a 0.1% reduction in medical care costs (elasticity).[2]
• In particular, the State will see a rapid reduction in Medicaid expenditures.  A 1 percentage point absolute reduction in smoking would be followed by a $46.3 million reduction in Colorado Medicaid costs.[3]
• The money no longer spent on tobacco products will be spent on other products that have higher economic and jobs multipliers in Colorado than tobacco products, contributing to tax revenues through increased economic activity and more employment.[4]
  • The reason for this is that little tobacco is grown and few tobacco products manufactured in Colorado, so most of the money spent on these products leaves Colorado resulting in smaller economic and jobs multipliers than the average dollar spent in Colorado.

The resulting cost savings and increased tax base more than offset the reductions in tobacco tax revenues, increasing funds available to support education and other state programs.

In particular, these funds could be used to more than offset reductions in tobacco tax revenues available for early childhood education.

HB 22-1064 is harm reduction.

In the hearings for HB 22-1064 opponents have consistently argued that eliminating flavors in e-cigarettes will reduce their “harm reduction” value as tools to help adult smokers quit.  While there are certainly some smokers who have successfully used e-cigarettes to stop smoking, this is the exception rather than the rule.  There is a large scientific literature showing that e-cigarettes as consumer products do not help smokers quit.[5]  Indeed, two recently published studies[6] that followed thousands of smokers for 3 years found that e-cigarettes made it significantly harder for smokers to quit.   Because they keep people smoking, e-cigarettes actually increase harm.

Reducing harm requires considering the benefits of ending flavored tobacco sales on youth.  Youth are much more than 5 times more likely to use e-cigarettes than adults: In 2020 19.6% among high school students[7] used e-cigarettes compared to only 3.7% of adults.[8]

Limiting sales to “adult only” venues will not address the problem because on 31% of youth purchase their own e-cigarettes.[9]  Exempting adult-only venues would be like building a dam one-third of the way across a river and expecting the flow to stop.

Passing comprehensive bans on the sales of flavored tobacco products will contribute to health now.  While the FDA has proposed strong rules eliminating menthol cigarettes and flavors in cigars, it has not proposed any such rule for e-cigarettes and other tobacco products popular with youth.  In addition, final implementation of the FDA’s proposed rules is, at best, years away.

Dr. Stanton Glantz retired in 2020 after 45 years as a Professor of Medicine and Founding Director of the University of California San Francisco Center for Tobacco Control Research and Education.  He has published over 470 peer reviewed papers and several books on cardiovascular research, secondhand smoke, e-cigarettes, economics of tobacco control and tobacco policymaking.  He served for 34 years on the California State Scientific Review Panel on Toxic Air Contaminants and is a member of the National Academy of Medicine.

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[1] https://leg.colorado.gov/sites/default/files/documents/2022A/bills/fn/2022a_hb1064_00.pdf

[2] Lightwood J, Anderson S, Glantz SA. Predictive validation and forecasts of short-term changes in healthcare expenditure associated with changes in smoking behavior in the United States. PLoS One. 2020 Jan 16;15(1):e0227493. doi: 10.1371/journal.pone.0227493. PMID: 31945079; PMCID: PMC6964879.

[3] Glantz SA. Estimation of 1-Year Changes in Medicaid Expenditures Associated With Reducing Cigarette Smoking Prevalence by 1. JAMA Netw Open. 2019 Apr 5;2(4):e192307. doi: 10.1001/jamanetworkopen.2019.2307. Erratum in: JAMA Netw Open. 2019 Jul 3;2(7):e198599. PMID: 30977860; PMCID: PMC6481435.

[4] Chaloupka, F.J. & Glantz, S.A. (2021). Potential Effects of a Ban on the Sale of Flavored Tobacco Products in California [Fact Sheet]. Tobacconomics. https://www.tobacconomics.org/files/research/671/ca-flavor-ban-and-revenues-3-29-21.pdf

[5] Wang RJ, Bhadriraju S, Glantz SA. E-Cigarette Use and Adult Cigarette Smoking Cessation: A Meta-Analysis. Am J Public Health. 2021 Feb;111(2):230-246. doi: 10.2105/AJPH.2020.305999. Epub 2020 Dec 22. PMID: 33351653; PMCID: PMC7811087.

[6] Osibogun O, Bursac Z, Maziak W. Longitudinal transition outcomes among adult dual users of e-cigarettes and cigarettes with the intention to quit in the United States: PATH Study (2013-2018). Prev Med Rep. 2022 Feb 28;26:101750. doi: 10.1016/j.pmedr.2022.101750. PMID: 35256929; PMCID: PMC8897625.

Chen R, Pierce JP, Leas EC, Benmarhnia T, Strong DR, White MM, Stone M, Trinidad DR, McMenamin SB, Messer K. Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017-2019. Tob Control. 2022 Feb 7:tobaccocontrol-2021-056901. doi: 10.1136/tobaccocontrol-2021-056901. Epub ahead of print. PMID: 35131948.

[7] Gentzke AS, Wang TW, Jamal A, Park-Lee E, Ren C, Cullen KA, Neff L. Tobacco Product Use Among Middle and High School Students – United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69(50):1881-8   PMCID 7745956

[8] Adjaye-Gbewonyo D, Boersma P. Early release of selected estimates based on Data from the 2020 National Health Interview Survey. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics,; 2021 [updated August 20216 May 2022]; Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/EarlyRelease202108-508.pdf.

[9] Gentzke AS, Wang TW, Cornelius M, Park-Lee E, Ren C, Sawdey MD, Cullen KA, Loretan C, Jamal A, Homa DM. Tobacco Product Use and Associated Factors Among Middle and High School Students – National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ 2022;71(5):1-29   PMCID 8923300