DOCTORS' LOUNGE
Fig 1. Young “vapers.”
Fig 2. Youth nicotine addiction
Fig. 3 KMA-sponsored school signs.
high-volume, bulk refilling bottles with over 5%
nicotine. Virtually all of these 106 products come
in several youth-attractive candy, fruit and dessert
flavors.
Fig 1.
Fig 2.
Fig. 3
and the chemicals responsible have not yet been
fully defined. User-added ingredients, such as marijuana extract
(THC oil) were involved in many of these incidents, adding another
dimension to the risks of vaping.
Among actions to suppress use by youth, bans on sales to
purchasers under 21 years of age have been proposed. These
initiatives have merit, but they need to be closely watched to be sure
industry lobbying influence does not introduce hidden provisions
that undermine their effectiveness. These have included state-law
provisions barring stricter local measures, omission of enforcement
mechanisms, or “tiny fines” for highly profitable corporate violations.
Such deceptive, lobbying-generated tactics have appeared in some
of 12 state laws that raised purchasing age limits. Also, black market
activity inevitably arises when desired substances are banned,
circumventing effectiveness of the restrictions.
Taxation offers another effective suppression measure. Tobacco-
products use has historically declined with price increases from
taxation, and early evidence shows this effect for e-cigarettes as
well. Currently, e-cigarettes are tax-free in Kentucky, as in 32 other
states. A last minute agreement in the 2018 Kentucky legislature
eliminated e-cigarette taxes from the bill that raised combustible
cigarette taxes from $0.60 to $1.10 per pack.
A reconsidering of e-cigarette taxation in the 2020 legislature
could allow Kentucky legislators an opportunity to lead the nation
by enacting an innovative and more effective taxation design. One
option could base taxes on nicotine delivery capability of the devices
and supplies, which would eliminate purchaser economic incentives
to adopt high-nicotine content products. Previous taxation enacted
by state or municipalities was based on price or e-juice volume,
not nicotine content. However, the enormous success of JUUL
in introducing high-nicotine delivery products (5.9% vs. 1.5-2%)
has created an escalating nicotine “arms race” among multiple
suppliers. A February 2019 British Medical Journal paper by Jackler
and Ramamurthi 1 lists over 13 JUUL-compatible pods and over 22
JUUL-emulating devices delivering nicotine content exceeding 5%.
Eon Smoke leads at 7%. In addition, the authors identified over 71
Representative Kim Moser of Taylor Mill,
Representative Jerry Miller of Louisville, and Senator
Julie Raque-Adams of Louisville have announced
intent to introduce bills imposing a 27.5% taxation
on Kentucky wholesale prices of all e-cigarette
products, which creates a rough equivalent to
that for combustible cigarettes. I have submitted
a resolution to the 2019 Kentucky Medical Association (KMA)
House of Delegates that urges taxation be scaled to nicotine delivery
capability, and I will communicate consideration of this approach
to these legislators.
In addition, a vigorous education program on vaping harm
especially directed to youth is needed. Our medical societies have a
history of leadership in such efforts. The Greater Louisville Medical
Society was a key element in support of Mayor Jerry Abramson’s
efforts to end restaurant smoking. The Fayette County Medical
Society was a leader in banning smoking in public places. The
KMA has been highly engaged and most effective in anti-smoking
initiatives statewide. Currently, the KMA, the Kentucky Foundation
for Medical Care, and the Foundation for a Healthy Kentucky have
partnered in providing “tobacco-free campus” signage to Kentucky
schools that ban smoking (Fig 3). This relieves each school of the
signage expense, and also removes the excuse of cost for not choosing
to become tobacco-free.
Much more should be done to support education efforts on
the harm of e-cigarettes. Our local, regional and state medical
societies must continue leadership and escalate efforts in these
needed education and legislative initiatives.
Dr. Tobin is a professor at the University of Louisville School of Medicine, Department
of Surgery, Division of Plastic and Reconstructive Surgery. He practices with UofL
Physicians-Plastic and Reconstructive Surgery.
References:
1: Bhatnagar A, Payne TJ, Robertson RM. Is there a role for electronic cigarettes in
tobacco cessation? Journal of the american heart association. 2019;8(12):012742.
doi:10.1161/JAHA.119.012742
2: Jackler RK, Ramamurthi D Nicotine arms race: JUUL and the high-nicotine
product market Tobacco Control Published Online First: 06 February 2019. doi:
10.1136/tobaccocontrol-2018-054796