Vaping Saves Lives

by on October 13, 2017 at 7:25 am in Economics, Law, Medicine | Permalink

E-cigarettes are less dangerous than cigarettes but are equally effective at delivering nicotine. Levy et al. estimate that if smokers switched to e-cigarettes millions of life-years would be saved, even taking into account plausible rates of non-smokers who start to vape. (It’s worth noting that the authors are all cancer researchers, statisticians and epidemiologists concerned with reducing cancer deaths.)

A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts.

Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.

Vaping saves lives but the FDA has in the past tried to impose severe regulations on the industry and to make vaping less pleasurable. (Aside: It’s interesting that liberals tend to favor other risk-reducing devices such as condoms in the classroom but disfavor vaping while conservatives often take the opposite sides. I don’t think either group is basing their choices on the elasticities.)

The FDA, for example, has tried to ban flavored e-cigarettes. In a new NBER paper, Buckell, Marti and Sindelar calculate that:

…a ban on flavored e-cigarettes would drive smokers to combustible cigarettes, which have been
found to be the more harmful way of getting nicotine (Goniewicz et al., 2017; Shahab et al., 2017).
In addition, such a ban reduces the appeal of e-cigarettes to those who are seeking to quit; ecigarettes
have proven useful as a cessation device for these individuals (Hartmann-Boyce et al.,
2016; Zhu et al., 2017), and we find that quitters have a preference for flavored e-cigarettes.

Fortunately, the new FDA commissioner Scott Gottlieb has signaled a more liberal attitude towards vaping. It could be the most consequential decision of his tenure.

Hat tip: The excellent Robert Wilbin from 80,000 Hours.

1 Alan October 13, 2017 at 7:33 am

Aside: It’s interesting that liberals tend to favor other risk-reducing devices such as condoms in the classroom

Schools have gotten a lot more liberal since I was young. We were told to tone it down if we were kissing too much in the hallway (Well, not we as in -me-, but some kids) now apparently they are using condoms in the classroom.

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2 A Truth Seeker October 13, 2017 at 8:09 am

“It’s interesting that liberals tend to favor other risk-reducing devices such as condoms in the classroom.”
It woukd be worse if they didn’t.

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3 albatross October 13, 2017 at 8:49 am

Damn, sex ed classes must be a *lot* more fun now than when I was a kid!

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4 A Truth Seeker October 13, 2017 at 8:55 am

But students are graded on their performance. Many find the pressure overwhelming.

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5 So Much For Subtlety October 13, 2017 at 9:30 am

Which is probably why young people today aren’t learning much.

Damn hard to make a mark when your chalk is wrapped in rubber.

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6 catter October 13, 2017 at 2:03 pm

Maybe also why they’re not doing it as much (per any number of studies discussed here and elsewhere)
Damn hard to enjoy something when middle-aged authority figures are harping on its technical details.

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7 Chip October 13, 2017 at 9:33 am

My 12-year-old daughter had a sex-ed class in which the teacher said they would learn that sex is “amazing.”

It can be, but still.

Yesterday, she had a substitute teacher for geography. A boy noted that New Zealand has more sheep than people. He was escorted from class for being “intolerant,” his voice echoing down the hallway: “but it’s true.”

We have some great teachers. Others are clearly lunatics.

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8 Kaym October 13, 2017 at 10:34 am

Last year my son got in trouble after his health teacher remarked that women are more likely to attempt suicide but men are more likely to succeed in it, and he remarked that it was because, like anything else, men know how to get the job done.

Apple didn’t fall far from the tree!

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9 mulp October 13, 2017 at 11:50 am

Marketing flavored vaping, etc, is like promoting condoms with prostitutes included in the purchase price.

Condom sales are increased by increasing the need for protected sex.

The economists arguing for fewer restrictions on vaping are arguing that the number of nicotine addicts is too small because too few people are starting to smoke or chew tobacco because those are considered disgusting.

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10 derek October 13, 2017 at 8:11 am

Vaping is fun, condoms are not.

Guess which Liberals are for and against.

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11 dearieme October 13, 2017 at 9:14 am

You may have the truth of it there. Have we been told yet whether Mr Weinstein was a condoms man?

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12 dearieme October 13, 2017 at 9:20 am

I can never find a condom that fits me, they all keep falling off no matter how small I buy.

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13 A Truth Seeker October 13, 2017 at 8:13 am

“Fortunately, the new FDA commissioner Scott Gottlieb has signaled a more liberal attitude towards vaping. It could be the most consequential decision of his tenure.”
So that’s it: America must surrender to vice so that Big Tobacco make money. At this point, only hypocrisy, not coherence, still keeps crack, LSD and cocaine illegal.

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14 Tim October 13, 2017 at 8:59 am

Big Tobacco is against vaping not for.

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15 A Truth Seeker October 13, 2017 at 9:21 am

Big Tobacco wants to corrupt and addict people, so they can earn blood-soaked money.

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16 mulp October 13, 2017 at 12:02 pm

Goutlier seems determined to increase nicotine addition to 25% to boost tobacco industry profits by way of vaping because the reductions to 15% have harmed tobacco industry profits and tax revenues.

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17 The Other Jim October 13, 2017 at 8:14 am

It’s politics, obviously. The best things the Dems ever did was get people to stop smoking. But the only reason they did this was to enrich their base (urban lawyers) at the expense of the GOP base (rural tobacco farmers). It just so happened to help people, so Dems took credit.

As for vaping, the Dems see it as just too close to smoking tobacco, and several of the same companies they fought the first time are profiting off of it. So purely from a marketing standpoint of protecting their party’s brand, they have to be against it. This just so happens to hurt people.

But don’t expect them to take any blame from the lefty news outlets. You are actually the first person I’ve seen to discuss it. You could run with it and make a name for yourself, if you were the intellectual and caring type… but that’s no way to get offered a Bloomberg column.

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18 Bill October 13, 2017 at 10:21 am

What are you smoking to cause these delusions?

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19 mulp October 13, 2017 at 12:04 pm

Your advocate getting the kids of conservatives and GOP addicted to nicotine by age 15?

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20 JWatts October 13, 2017 at 8:18 am

“Aside: It’s interesting that liberals tend to favor other risk-reducing devices such as condoms in the classroom but disfavor vaping while conservatives often take the opposite sides. I don’t think either group is basing their choices on the elasticities.”

I’m pretty sure that conservatives aren’t in favor of vaping in the classroom either……

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21 Ralt Ight October 13, 2017 at 9:13 am

+1

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22 Oakley October 13, 2017 at 10:14 am

Both liberals and conservatives STRONGLY favor coercive government interventions into the peaceful personal lives of all citizens. They merely disagree on the specific interventions desired.

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23 Doug October 13, 2017 at 8:34 am

100% agree with you, Alex. But minor wobble here:

>E-cigarettes… are equally effective at delivering nicotine

This is true, but modern research has found that the addictiveness of tobacco is not due to nicotine alone. The plant also contains a number of MAOIs which act in concert with nicotine to have an anti depressant effect. Alone nicotine is a minor stimulalent no more addictive than caffeine in rat studies.

This is why so many smokers find nicotine replacement therapy ineffective. As a practical advice if you’re quitting smoking you should think about tobacco derived replacement, either tobacco derived e-liquid or snus.

And if you, like me, are a non smoker looking to enjoy the numerous proven cognitive and health benefits of nicotine, stay completely away from any tobacco derived source.

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24 Hoosier October 13, 2017 at 8:46 am

Wow, great comment. Was not aware of the MAOIs and there anti-depressant properties. I only have smoked a handful of times in my life, but when I did I definitely felt a slight pick me up so this makes sense. My lungs always hurt the next day though. If it wasn’t for that, and me being cheap, I would probably be smoking today.

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25 Jeff R October 13, 2017 at 10:02 am

I had suspected something likethat was the case, so thanks for spelling that out. I have a few smoker friends/coworkers who tried e-cigarettes and I think all of them switched back to regular cigarettes, most of them sooner rather than later.

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26 Oakley October 13, 2017 at 10:03 am

Yes …. and it’s critical to note that there is NO Nicotine in many E-Cigarettes in use.

Nicotine is an OPTIONAL additive chosen by the user …. and can be easily varied from zero to slight to heavy, at user discretion.
Primary ingredient in E-Cigarette vapor is harmless, food-quality glycol. Many users simply fill their E-Cigarette reservoir with flavored (non-nicotine) glycol fluid …. totally harmless.

The habit-forming mode of tobacco smoking is largely due to the frequent psychological/manual “ritual” of one interrupting what they are doing/thinking at the moment …. and distracting themselves with a stress-relieving break.
E-Cigarettes duplicate this personal ritual without nicotine/tar/etc danger.

(the whole issue of chemical-addiction is a separate and widely misunderstood issue)

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27 V October 13, 2017 at 11:45 am

Psychiatrist here. Good comment Doug, but incorrect. MAOIs mechanism of action is independent of nicotine. Nicotine is much more addictive than caffeine. Nicotine replacement therapy is relatively successful as far as medications go. Varenicline is not tobacco derived and is much better than snus for quitting smoking.

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28 chuck martel October 13, 2017 at 8:44 am

Vaping is just one technique among several being developed to deliver nicotine with fewer externalities to non-smokers and thwarting bans on use in public. The most effective of these might be the new nicotine suppositories, although not everyone is expected to adopt them.

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29 cjcjc October 13, 2017 at 8:45 am

Clearly a mistake to disregard condom elasticity.

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30 dearieme October 13, 2017 at 9:17 am

I wonder whether smoking a pipe is a decent compromise between life-lengthening and pleasure.

Pipe smoke is far less offensive to this non-smoker than cigarette smoke.

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31 dearime October 13, 2017 at 9:30 am

Or cock smoking

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32 Floccina October 13, 2017 at 9:28 am

Government would do less harm subsidizing vaping. Why is Government so crazy?

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33 Michael Phippen October 13, 2017 at 9:41 am

When are you going address the potential effects of Scott Pruitt, it seems you could comment on the potential outcomes of what seems to be the new EPA’s direction and it’s environmental consequence. There must be some new data or paper discussing the ramifications of oil and gas, chemical and big pharma’s new opportunities for environmental plunder and the resulting stock performance of winners.

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34 Bozhidar October 13, 2017 at 10:04 am

10 years pass and then researchers will find out that e-cigs are actually inducing cancer…

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35 Stuart October 13, 2017 at 10:10 am

I think this post could benefit from putting a few sentences toward providing the strongest argument the pro-vaping regulation side has, and why it’s not persuasive. There are many other people who devote their lives toward fighting the health affects of tobacco, and they are wary of vaping, and presumably they have a reason.

If you read an anti-vaping post, I think you’d similarly appreciate if they at least took the time to ID and address the strongest pro-vaping argument.

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36 Stuart October 13, 2017 at 10:12 am

Also, I think the FDA’s suggestion they bring nicotine levels in cigarettes down to non-addictive levels would be the most significant health development they’d have in this admin, if it happens.

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37 Hazel Meade October 13, 2017 at 10:31 am

People would just smoke more cigarettes – which would be even worse for their health.
If you make it so low it’s impossible to get a buzz off of cigarettes you’ll end up with a black market in “real” tobaccoo products.

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38 Boonton October 13, 2017 at 1:22 pm

Actually I doubt that. A huge part of ‘buzz’ is psychological and a non-trivial part of smoking’s appeal is the comfort of the habit, the mental image of what people thinks it looks like, etc.

But what I’m wondering is what exactly is the problem with nicotine addiction? If you strip out the tar and other carcinogens that come with smoking, then how bad is it to simply have a nicotine addiction for your whole life?

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39 Tom Bri October 15, 2017 at 7:07 am

Nicotine itself has some bad effects. It causes small blood vessel growth, which can help tumors grow faster. It also can cause vaso-spasm leading to narrowing of arteries. A cardiac doc I work with who does stenting refuses to give prescriptions for nicotine patches after a stent placement, for this reason.

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40 Boonton October 13, 2017 at 10:16 am

What is the mechanism that a ban on ‘flavored’ vape juice will drive people to smoke cigarettes? Flavored cigarettes do not exist, at lest nothing like the flavors that vape companies are putting out.

When my nephew was in middle school, he told me a story about kids who got in trouble for opening the door for a high school kid to sneak in, the kid was engaged in some convoluted plan to sell an e-cigarette to a middle school kid.

I think vaping is positive on net but I suspect we are underestimating just how many kids are taking up vaping as supposedly ‘safe smoking’, the extinction of smoking may end up being replaced by its revival via vaping…we have yet to see what the long term health effects of vaping will be and I get a funny sense that a lot of these companies appear to be fly by night outfits hawking ‘juice’ that many of us are in the dark about.

(Aside: It’s interesting that liberals tend to favor other risk-reducing devices such as condoms in the classroom but disfavor vaping while conservatives often take the opposite sides. I don’t think either group is basing their choices on the elasticities.)

1. Condoms are regulated by the FDA. Buy cheap ‘off label’ brands or premium ones and you know what you’re getting functions in terms of a medical device.

2. Conservatives think sex being risky is a feature, not a bug. AS they are unwilling to make moral arguments against sex, they would rather cling to secular based arguments (say by questioning the effectiveness of condoms).

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41 Boonton October 13, 2017 at 10:20 am

Also keep in mind in the US most conservatives are heavily influenced by the Christian Non-Mormon right. I think if you had Mormon’s playing a larger role in mainstream conservativism, you might see less of an embrace for ‘vaping’ which, like condoms, seems to preserve the ‘fun’ while filtering some of the bad out of a prohibited activity.

On the non-Mormon Christian front, preachers may advise against smoking but few make it much of a moral issue or have any deep theological objection to it.

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42 Albigensian October 13, 2017 at 10:20 am

The assumption here is that cigarette smokers will switch to e-cigs.

The FDA’s concern is that non-smokers who might never start smoking real cigarettes will start vaping. Which, given the lack of control over what goes into the vaping fluid, contains at least some potential for harm.

Of course, the libertarian view is that it’s no one’s business what drugs one chooses to use (let alone the method used to deliver them). Nonetheless, Reason Magazine would be more interesting if it didn’t obsess so about legalizing drugs.

In any case, e-cigs are an improvement over “smokeless tobacco” snuff stuff, at least regarding the aesthetics of public spaces. And probably over real cigarettes as well (because no butts).

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43 Hazel Meade October 13, 2017 at 10:42 am

Reason would be more interesting if they had more articles emphasizing economic policy issues.

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44 WP October 13, 2017 at 12:25 pm

I stopped reading it because of all the culture-war crap. They seem unable to understand that you can be a libertarian without being a cuck.

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45 Boonton October 13, 2017 at 11:50 am

My personal impression is that vaping as a substitute for smoking has been pretty successful for younger smokers. Older smokers are reluctant because it’s ‘new’ and unless they are purposefully trying to quite or reduce risk, they would rather go with the old school method of real smoking.

Just an observation, I’ve seen vape stuff *added* in many stores and I’ve seen lots of dedicated vape stores opening but I don’t think I’ve noticed any decline in store space dedicated to cigarettes. You would think if vaping was converting people from tobacco it would be making an impact on tobacco retail sales and eventually reduced space dedicated to it.

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46 OldCurmudgeon October 13, 2017 at 11:55 am

Charitably, it’s the old “gateway drug” theory. Regularizing vaping correlates with experimenting with cigarettes, which correlates with more getting addicted, which correlates with more deaths.

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47 Clyde Schechter October 13, 2017 at 10:31 am

I think the concerns that those who have opposed vaping have are legitimate, but lacking an evidence base at this point. It has always been obvious that if vaping replaced cigarette smoking, many lives would be saved and many serious illnesses avoided. Nobody ever doubted that. The real contribution of Levy et al. is quantifying that.

The real question is what will actually happen if we loosen restrictions on vaping. If it does replace cigarette smoking, it’s a big public health win. But if it serves as a gateway to smoking and leads to increased smoking, then it’s a huge setback, reversing the hard-won progress of decades of anti-smoking initiatives. The opposition to flavorings, in particular, is based on a concern that it will entice children to vape, and that they will then “graduate” to smoking. If that happens on a large scale the harm done will outweigh the benefits of making vaping attractive to people who want to quit.

In truth, we don’t know what the interplay between vaping and smoking will be, and much may depend on the marketing approaches used, which are difficult to foresee. A randomized controlled trial does not seem possible. So it seems to me that while this shakes out the sensible approach is to start with strong regulations and periodically adjust them, carefully monitoring the actual usage patterns of vaping and smoking as we go until we find the point (which might be complete absence of regulations or stringent regulation or anywhere in between) that leads to the greatest population health benefit.

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48 Boonton October 13, 2017 at 11:40 am

“The real question is what will actually happen if we loosen restrictions on vaping.”

This is not how regulation works. An innovation appears on the scene and it is roughly in ‘the wild west’. More or less anything goes until problems are seen and then regulations are figured out to address them.

For example, when vaping first appeared people started doing it everywhere that they would never even consider smoking (like inside planes). Then the arguments for a modification of the regulation came into play (pro: vaping doesn’t produce true smoke; con an enclosed room full of vapers can be pretty annoying to everyone else ).

The two problems that seem to scream out for regulation are IMO:

1. The question of what exactly is in ‘vape juice’ and how it is made. What can and can’t be added to it and how do we know it is safe and honestly labelled?

2. The question of whether vaping will become a product beyond an alternative for smoking. This is already happening, there are lot of kids IMO who vape that would have never picked up an actual cigarette. Proposals to ban candy like ‘flavors’ are along these lines.

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49 poorlando October 13, 2017 at 12:20 pm

The sensible approach is to start with no regulations and then to add a limited set of them only when the evidence is very clear that they are needed.

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50 mpowell October 13, 2017 at 12:28 pm

What if we were not talking about vaping but a minor modification of a cigarette itself? How long do we have to wait before deciding manufacturers cannot advertise heavily towards teens to get them addicted early in life? It really is possible and reasonable to start with priors on the likelihood of bad outcomes from a product even before evidence starts to emerge. A ‘must wait until definitive evidence emerges’ is only going to persuade the most die-hard libertarian. From any other perspective, the argument is absurd.

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51 mpowell October 13, 2017 at 12:22 pm

I think this captures the crux of the issue. It should not have been left to the comments to point this out. In this sense, I think the conservative reaction (not in a political party sense) is to be somewhat wary of vaping and wait for the data to develop a bit more. There’s a big delta between the optimistic vs pessimistic scenarios which indicates that if the pessimistic scenario is not adequately pessimistic and vaping becomes a habit for would be non-smokers and, even worse, transitions them to smoking, the health consequences can very easily become negative. It is really a very big mistake to take someone’s ‘pessimistic’ scenario at face value and assume your policy intervention cannot flip from positive to negative.

In a big picture I would not worry too much about the health implications for adults making their own choices, but smoking is different because there is a long history of tobacco manufacturers targeting minors to get them addicted and become long term consumers. There is no reason for a mature vaping industry not to do the exact same thing and it would happen to a significant extent regardless of what the marketing departments of these firms do. Even a libertarian may appreciate a valid role for the state in regulating activity that has a material effect on lifelong health outcomes based substantially on the activities of minors.

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52 Hazel Meade October 13, 2017 at 10:55 am

I think the flavored vape cartridges actually come from hookah smoking, which is also popular with hipsters. It has nothing to do with enticing children. Hookah tobacco (shisha) also comes in lots of different flavors, and nobody seems to think that hookah bars are trying to entice children.

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53 Boonton October 13, 2017 at 11:45 am

Hookah bars are not trying to entice children. Hookah predates vaping and is not really practical to do on the go the way you can with regular smoking or vaping.

That doesn’t change the fact that flavored vape cartridges are quite likely to entice children and that would be very lucrative for the vape industry to push since the market for a smoking substitute is limited

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54 Paraguayan October 13, 2017 at 11:04 am

Terrible comments. Paraguayans have more dignity.

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55 swb October 13, 2017 at 12:03 pm

Vaping is a great way to deliver a wide variety of unknown and unregulated chemicals directly into your lungs where they can easily be absorbed in to the blood stream and spread throughout the body. I am sure that all the companies that produce the chemicals have exhaustive tests to determine the long term effects of those chemicals, so there is nothing to worry about. Even if there are problems, the free market will handle them, i would expect an entire industry to be developed to cater to long term care of “vaping lung”. The economic benefits will add significantly to the GDP.

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56 Brett A Powers October 13, 2017 at 1:20 pm

Is this certainly true? The benefits of smoking were widely touted as late as the ’50s, due to the fact that consequences of long-term use were still unknown.

I am not havinly debating that vaping is superior to smoking. But I am VERY uneasy about any claim that even hints that it still might be a good thing to do, given chronic usage effects are currently unknown.

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57 Brett A Powers October 13, 2017 at 1:21 pm

for “havinly” please read “heavily.” Keypads suck.

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58 drearime October 13, 2017 at 2:17 pm

Keypads cuck.

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59 psmith October 13, 2017 at 5:13 pm

snus master race

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