Public health experts have written to the FDA urging commissioner Scott Gottlieb to respond to the latest youth vaping statistics with ‘proportionate and reasonable action’.

The letter was sent by Iowa Attorney General, Thomas J Miller, signed by signatories including the UK’s Clive Bates.

The Attorney General acknowledged that there was a difficult balance to maintain between encouraging vaping as an ‘off-ramp’ for smokers and and an ‘on-ramp’ for teens taking up nicotine.

Half a million Americans die from smoking-related illnesses each year.

Mr Miller wrote:

• It is essential to distinguish between adolescent occasional use and regular or daily use and to focus policy on addressing the latter, while not over-reacting to the former.

• The most intensive adolescent e-cigarette users are far more likely to also be smokers. They may potentially benefit from e-cigarette use. There is no ethical basis for ignoring public
health harm reduction benefits to those under 18.

• The risks of vaping should not be exaggerated, and any policy response should be proportionate to risk. Even though there will be residual uncertainty about the long-term health risks until these products have been used for several decades, we know enough now to be confident that these products pose little direct risk to either adults or adolescents compared to smoking or to many common youth risk behaviors.

• Vaping by youth is primarily a concern only to the extent it will lead to cigarette smoking, and there is little evidence suggesting that vaping itself causes regular smoking. Regular use of vapor products is a concern because it could be indicative of emerging dependence. If young people become dependent on nicotine through vaping, then removal from the market of the products they are using could lead to unpredictable behavioral responses, including uptake or increase of smoking – the outcome that FDA and the public health community seeks to avoid.

• It is not possible to separate neatly the interests of adults and adolescents. Parental and role-model smoking is a major risk factor for youth initiation. Young people suffer significant harm when a parent or other significant people in their lives die or are incapacitated by smoking-related disease. All adolescents grow to become adults and their wellbeing is a product of risks and opportunities available through the life-course. Young people have a stake in the adult society they will grow into.

• Even if FDA can identify causal connections between product characteristics, such as flavors, and uptake of youth vaping, there are further difficulties in establishing the effects of any
intervention on youth behavior and whether this will cause net harms or net benefits.

• FDA’s comprehensive strategy for nicotine has a clear long-term objective to protect young people from initiating with the most harmful products. But this strategy is highly contingent on the availability of appealing and effective alternatives to smoking. A hasty response that does not consider the harm reduction potential for adults could render FDA’s broader strategy inoperable.