Article
Commentary: Forces That Drive the Vape Shop Industry and Implications for the Health Professions
Evaluation & the Health Professions 1-10 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0163278715586295 ehp.sagepub.com
Steve Sussman1,2,3, Lourdes Baezconde-Garbanati1,4, Robert Garcia1, Dianne C. Barker5, Jonathan M. Samet1, Adam Leventhal1,2, and Jennifer B. Unger1
Abstract At least three factors may be driving the evolution of the vape shop industry, a rapidly growing market sector that specializes in the sales of electronic cigarettes: (1) the tobacco industry, (2) the public health sector and its diverse stakeholders, and (3) consumer demand. These influences and the responses of the vape shop sector have resulted in a rapidly
1
Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA Department of Psychology, University of Southern California, Los Angeles, CA, USA 3 School of Social Work, University of Southern California, Los Angeles, CA, USA 4 Department of Sociology, University of Southern California, Los Angeles, CA, USA 5 Barker Bi-Coastal Health Consultants, Inc., Calabasas, CA, USA 2
Corresponding Author: Steve Sussman, Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA. Email: [email protected]
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
2
Evaluation & the Health Professions
changing landscape. This commentary briefly discusses these three factors and the implications for the health professions, as they address the vape shop industry and its consequences for public health. Keywords vape shops, electronic cigarettes, health
Electronic cigarettes or e-cigarettes are battery-powered devices that are used to vaporize a propylene glycol (PG) and/or vegetable glycerin (VG) solution, generally with some type of flavoring, and which may also contain liquid nicotine in various concentrations. There are also e-cigarettes that do not contain nicotine. E-cigarettes may be disposable (e.g., Blu and Njoy disposable brands often sold at convenience stores) or rechargeable (with battery chargers, heating coils, and liquid solution). E-cigarette users (often called ‘‘vapers’’) inhale a vapor that does not contain many of the toxic compounds in cigarette smoke generated by combustion that contribute to the extremely high risk of disease and premature death in smokers (Sussman et al., 2014). In the last few years, ‘‘vape shops’’ have proliferated in various countries, including the United States (retrieved April 19, 2015, from http://www.bloomberg.com/bw/articles/2013-10-03/healthymarkups-on-e-cigarettes-turn-vacant-storefronts-into-vape-shops). These shops are so named because they specialize in the sales of e-cigarette products. There are at least 3,500 vape shops in the United States (Klein, 2013; Lee & Kim, 2014), though estimates of 6,000–7,000 (retrieved April 19, 2015, from http://vapenewsmagazine.com/november-2014/ how-many-vape-shops-are-there-in-the-u-s-a) and as high as 35,000 shops have been made (Kamerow, 2014). Unlike other retailers, most vape shops allow users to sample several types of electronic juices (e-juices), mostly using rechargeable devices. Vape shops sell a variety of types of refillable (and, rarely, disposable) e-cigarettes, several types of solution strengths and flavors, more complex and powerful tank systems that offer customized vaping experiences for experienced users, and sometimes other accessories (e.g., T-shirts). The vape shop business visibility is rapidly increasing. For example, a Google search for ‘‘vape shops’’ with ‘‘Los Angeles’’ revealed over 5,000 pages (retrieved December 20, 2013), which increased to over 88,300 pages in 16 months (retrieved April 15, 2015). The markup on e-cigarettes can be 200–400% (compared to 10–20% for combustible cigarettes), which may
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
3
account for the unprecedented growth in the prevalence of such shops (Klein, 2013; Lee & Kim, 2014), with total e-cigarette sales worldwide being over US$3.5 billion (retrieved April 19, 2015, from http://www.reuters.com/ article/2014/09/12/us-tobacco-ecigarettes-insight-idUSKBN0H711I20140912). Sales of e-cigarette products in vape shops likely are quite high, although traditional measures (e.g., the Nielsen Company) have not included vape shops yet as retailers (Giovenco, Hammond, Corey, Ambrose, & Delnevo, 2015). It is not yet possible to accurately calculate the price elasticity of vape shop–related vaping (Huang, Tauras, & Chaloupka, 2013), and the future growth of vape shops is uncertain (retrieved April 19, 2015, from http://ecigone.com/featured/future-history-e-cigarette-industry/). The proliferation of vape shops ultimately may have a negative impact on health behaviors and health outcomes. E-cigarettes when heated may generate carcinogenic components in the vapor, the production and composition of flavorings are not regulated, and nicotine itself is addictive, may raise blood pressure, and has deleterious effects on youth and on the fetus during pregnancy (Chapman, 2015; Grana, Benowitz, & Glantz, 2014; U.S. Department of Health and Human Services, 2014). Spills and lack of other safety precautions such as not wearing gloves or goggles while handling juices, or liquid nicotine, or while drilling air holes or rebuilding, at the vape shops may also cause risks to workers and patrons through suffering nicotine toxicity and other effects of coming into contact with e-juice (Pearson, 2014). Also, to the extent that purchasers do not use e-cigarettes to stop smoking traditional, combustible cigarettes but instead use them along with combustible cigarettes (dual use) to remain nicotine dependent, these shops may indirectly promote continued use of a variety of tobacco and nicotine-containing products (Grana et al., 2014). Empirical and theoretical studies regarding this alternative market are now only beginning to be published, which generally involves nicotine delivery. Even as descriptive articles are being published, the vape shop enterprise is a very dynamically changing context right now. In the present commentary, we describe three factors that appear to be driving the evolution of the vape shop industry. First, the vape shop industry appears to be offering an alternative market to that of the tobacco industry. That is, vape shops offer an alternative product to combustible tobacco, the latter long being the mainstay of the tobacco industry. Second, the public health community and its stakeholders are responding to the emergence of e-cigarettes vigorously but with diverse views. For
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
4
Evaluation & the Health Professions
some stakeholders in the public health and medical professions, the vape shop industry offers a product that is viewed as valuable for harm reduction, whereas others are concerned that wide availability of ecigarettes, particularly with flavorings, may promote nicotine addiction among youth and lead to dual use. Third, there is an appeal of the product to customers and a demand for better and less expensive products. In this commentary, we describe these factors, suggest ways that the vape shop industry is responding, and address some implications for the health professions.
Tobacco Industry The relationship between the vape shop industry and the tobacco industry is adversarial in general, besides the presence of some ‘‘vape and smoke’’ shops that, anecdotally, are rejected by a majority of the vape shop industry. Most vape shops do not sell disposable or rechargeable brands that are owned by ‘‘Big Tobacco’’ companies, such as Blu (owned by Lorillard), Vuse (owned by R. J. Reynolds), and MarkTen (owned by Altria), preferring to stock products that are manufactured independently of tobacco industry influence (Kamerow, 2014). The tobacco industry is responding to this stance. Recently, Reynolds American filed a 119-page submission to the Food and Drug Administration (FDA) to ban the use of opensystem vapor e-cigarettes, which may interfere with vape shop practices (retrieved April 16, 2015, from http://www.journalnow.com/business/business_news/local/reynolds-american-wants-fda-to-ban-vapor-e-cigs/article_ 77b131f5-540d-5f02-927c-733bac751529.html). The reaction of the vape shop industry to such tobacco industry actions has been to claim that the tobacco industry is trying to stop competition. Vape shop owners in general continue to not sell tobacco industry items and publically express fear or distrust of the tobacco industry. Anecdotally, electronic cigarettes are starting to be referred to more as ‘‘personal electronic vaporizing units’’ in shops, in part, to dissociate them from combustible ‘‘cigarettes’’ (retrieved April 20, 2015, from http://sfata.org/blog/front_tabs/product-design/). In addition, pro-vaping activism groups such as Consumer Advocates for Smokefree Alternatives Association (CASAA) have exerted their own efforts to influence decisions that might be made by the FDA (retrieved April 17, 2015, from see http://blog.casaa.org/2015/04/call-to-action-submitcomments-on-fdas.html).
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
5
Public Health Sector and Its Stakeholders A second source of pressure comes from the public health sector and their stakeholders (e.g., local governments and nonvapors). With the assumption that e-cigarettes may be dangerous to users and persons exposed to vapor (e.g., nicotine itself has negative consequences, some flavorings are dangerous, such as diacetyl, and there may be dangers of PG and VG released in vapor aerosol; see Grana, Benowitz, & Glantz, 2014), restrictions on the number and location of vape shops, types and content of e-juices, and ability to vape within shops are being considered at the local level. While there is some debate, in general, the public health sector is hesitant to recommend e-cigarettes as a means to quit combustible cigarettes (e.g., Ebbert, Agunwamba, & Rutten, 2015), and calls for the regulation of e-cigarettes have been made that explicitly mention vape shops as a distribution channel (e.g., Brandon et al., 2015; Digulio, 2015). Speaking as chief of the California Department of Public Health, Chapman (2015) mentioned that ecigarettes emit at least 10 chemicals on California’s Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive harm. He further asserted an urgent need for education about e-cigarettes, protection of minors, application of all combustible cigarette policies to ecigarettes, and protections to the general population from e-liquids and ecigarette-related aerosols. Likewise, Grana, Benowitz, and Glantz (2014) made policy recommendations including prohibiting the use of e-cigarettes anywhere that the use of combustible cigarettes is prohibited (e.g., as operates in North Dakota, New Jersey, and Utah; partial restrictions exist in 18 states; American Nonsmokers’ Rights Foundation [ANRF], retrieved April 30, 2015, from http:// www.no-smoke.org/pdf/ecigslaws.pdf), prohibiting the sale of e-cigarettes to anyone who cannot legally buy cigarettes or in any venues where the sale of combustible cigarettes is prohibited, subjecting e-cigarette marketing to the same level of restrictions that apply to combustible cigarettes (including no television or radio advertising), prohibiting co-branding e-cigarettes with combustible cigarettes or marketing in a way that promotes dual use, prohibiting the use of characterizing flavors in e-cigarettes (particularly candy and alcohol flavors and flavors that would be attractive to youth), prohibiting claims that e-cigarettes are effective smoking cessation aids until e-cigarette companies provide sufficient evidence that e-cigarettes can be used effectively for smoking cessation, prohibiting any health claims for e-cigarette products until unless approved by regulatory agencies as meeting scientific standards, and establishing standard policies for regulating the
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
6
Evaluation & the Health Professions
ingredients of any tobacco-derived nicotine containing product. A proposed ‘‘deeming rule’’ (see 21 Code of Federal Regulations Parts 1100, 1140, and 1143) may facilitate these policies being set in place (retrieved April 15, 2015, from, http://www.fda.gov/TobaccoProducts/Labeling/ucm388395.htm). Also, consequently, local government city councils and nonvape shop business owners have petitions under review to prohibit vape shops in their jurisdictions (e.g., in Highland Park, Long Beach, Monterey Park, and Pasadena, California). Conversely, the European Commission proposed some regulations that would permit e-cigarettes to be viewed as medications useful to wean one off of combustible cigarettes (retrieved April 16, 2015, from http://www.economist.com/news/leaders/21586855european-lawmakers-should-reject-proposals-control-electronic-cigarettesstrictly). The vape shop industry has been responding to these public health measures. Responses are provided on vape shop-related websites as well as informally among vape shop owners and customers. For example, one wellknown website (retrieved April 16, 2015, from http://www.e-cigarette-forum.com/forum/) discusses in a forum format (a) e-cigarette legislation at the U.S. federal and state level, (b) FDA regulations and proposals including the deeming rule, (c) European Union legislation, (d) campaigning ideas to support e-cigarette use, (e) local laws on sales of e-cigarettes, (f) CASAA forum, and (g) Electronic Cigarette Consumers Association of the United Kingdom (ECCA UK), the U.K. consumer association forum. Another anecdotal example, after some recent instances of nicotine poisoning among infants (e.g., Bassett, Osterhoudt, & Brabazon, 2014), the vape shop industry has responded with increasing use of child safety caps on e-liquid bottles, as well as safety warnings and ingredient listings on e-juice bottles. The vape shop industry also keeps abreast of scientific research that supports cessation of combustible cigarettes through vaping (e.g., retrieved April 19, 2015, from http://www.ecigarette-research.com/web/index.php). One recent research study of 71 adult (mean age ¼ 41) combustible cigarette smokers in Sicily who went to vape shops to quit combustible cigarettes showed a 41% intent-to-treat (ITT) combustible cigarette quit rate 12 months after beginning vaping (Polosa, Caponnetto, Cibella, & LeHouezec, 2015). While there was no comparison group and the sample was one of convenience, these results were promising in terms of vapor e-cigarettes serving as a means of cessation from combustible cigarettes. This article is likely to appear on vaping forums soon along with some others that indicate decrease in the use of combustible cigarettes along with an increase in the use of e-cigarettes among adults recruited in vape shops
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
7
(Berg, Barr, Stratton, Escoffery, & Kegler, 2014 [23% ITT quit rate]; Lechner et al., 2015; McRobbie, Bullen, Hartmann-Boyce, & Hajek, 2014; Meier & Wagener, 2014), although the quality of available empirical work generally is low and not all published work demonstrates relatively greater cessation among those using e-cigarettes compared to nonvaping controls (see Grana et al., 2014).
Consumer Demand The third source of pressure is customer demand. Sussman et al. (2014) conducted a Yelp electronic search and content analysis of consumer reports concerning vape shops that they have visited. The primary measure was Yelp reviews (N ¼ 103 vape shops in the Los Angeles, California area), which were retrieved and content coded. They compared the attributes of vape shops representing four ethnic communities, African American, Hispanic/ Latino, Korean, and White and found that vape shop attributes listed as most important were the selection of flavors or hardware (95%), fair prices (92%), and unique flavors or hardware (89%). Relatively few of the reviews mentioned quitting smoking (32%) or safety of e-cigarettes (15%). Thus, consumers appear to desire more efficient, practical, low-cost vaping devices and an ever-increasing variety of types of vapor devices and flavors. Notably, based on an extensive search of electronic websites, Zhu et al. (2014) reported that there were 466 brands of e-cigarettes and 7,764 e-juice flavors at that time. Currently, a new box-type modular device (box mod e-cigarette), which permits regulating ohms (resistance) through use of a memory chip and is increasingly affordable, is taking the place of tubular, more inefficient devices (retrieved April 12, 2015, from http://www.vaporizerviews.com/ box-mods/). Anecdotally, the availability of vape magazines that appear in shops (e.g., VPR; retrieved April 20, 2015, from https://www.vprmag.com/), ‘‘cloud chasing’’ contests, televisions, and sometimes food and beverages, and couches appear to provide a means of having patrons spend time in the shops as well as consume products (e.g., Sussman et al., 2014). Certainly, store owners perceive e-cigarettes as much more safe than combustible cigarettes, offer sophisticated marketing approaches including loyalty point incentives for customers, and make vape shops an environment in which customers can socialize (e.g., Cheney, Gowin, & Wann, 2015; Sussman et al., 2014). In summary, in order to maintain and increase revenue streams as well as to provide a useful service to their customers, vape shops are motivated to respond to pressures from their consumers—pressures that are rapidly changing.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
8
Evaluation & the Health Professions
Conclusions: Implications for the Health Professions Tracking of vape shops is needed to inform future regulations, educate the health professions about similarities and differences between vape shops and traditional tobacco retail outlets (e.g., convenience stores) predominately selling disposable e-cigarettes, and assist persons in the health professions to decide how to advise their patients who want to quit smoking combustible cigarettes. Learning more about the physical environment of vape shops, as well as about the products sold, provides a ‘‘big picture’’ of marketing strategies to understand what may lead consumers to initiate and maintain a vaping habit (e.g., Sussman et al., 2014) and possibly help combustible tobacco smokers wanting to quit who have not been successful with existing evidence-based cessation products. Potential for long-term dual use of combustible and e-cigarettes, and to ‘‘hook’’ nonsmokers who otherwise might avoid nicotine addiction, needs highlighting. A greater understanding of how minors’ access laws (now in place in 42 states and one territory; retrieved April 20, 2015, from http://www.ncsl.org/ research/health/alternative-nicotine-products-e-cigarettes.aspx; also see Marynak et al., 2014), and safety precautions for e-juice production, are being voluntarily enforced by vape shops is warranted. At this time, it appears that several health experts see the promise of e-cigarettes as a means of cessation for longtime adult combustible cigarette smokers. However, more research is needed. Among other issues is that, in many shops, vape shop clerks are being put in the role of smoking cessation counselors, probably with minimal training. Tentatively, training of vape shop employees in evidence-based smoking cessation techniques including how best to help customers eventually titrate down to zero nicotine liquids and possibly, eventual abstinence, if desired, is recommended. However, additional research is needed on how to implement this strategy. Vape shops will undoubtedly continue to evolve, given the forces that we described. While the long-term impact of vape shops on the public health is yet to be determined, we contend that understanding the various sources of influence on vape shop practices will be important for developing and implementing public health surveillance and policies that address this critical segment of the nicotine marketplace. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
9
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by grant number DA020138 from the National Institute on Drug Abuse and by grant number P50CA180905 from the National Cancer Institute and Food and Drug Administration (FDA) Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.
References Bassett, R. A., Osterhoudt, K., & Brabazon, T. (2014). Nicotine poisoning in an infant. New England Journal of Medicine, 370, 2249–2250. Berg, C. J., Barr, D. B., Stratton, E., Escoffery, C., & Kegler, M. (2014). Attitudes toward e-cigarettes, reasons for initiating e-cigarette use, and changes in smoking behavior after initiation: A pilot longitudinal study of regular cigarette smokers. Open Journal of Preventive Medicine, 4, 789–800. Brandon, T. H., Goniewicz, M. L., Hanna, N. H., Hatsukami, D. K., Herbst, R. S., Hobin, J. A., . . . Warren, G. W. (2015). Electronic nicotine delivery systems: A policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology. Journal of Clinical Oncology, 33, 952–963. Chapman, R. (2015). State health officer’s report on e-cigarettes: A community health threat. Sacramento: California Department of Public Health, California Tobacco Control Program. Cheney, M., Gowin, M., & Wann, T. F. (2015). Marketing practices of vapor store owners. American Journal of Public Health (published online April 16, 2015), e1–e6. Digulio, S. (2015). AACR and ASCO jointly call for federal regulation of e-cigarettes. Oncology Times, 37, 28–29. Ebbert, J. O., Agunwamba, A. A., & Rutten, L. J. (2015). Counseling patients on the use of electronic cigarettes. Mayo Clinic Proceedings, 90, 128–134. Giovenco, D. P., Hammond, D., Corey, C. G., Ambrose, B. K., & Delnevo, C. D. (2015). E-cigarette market trends in traditional U.S. retail channels, 2012– 2013. Nicotine & Tobacco Research (published online January 15, 2015). Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: A scientific review. Circulation, 129, 1972–1986. Huang, J., Tauras, J., & Chaloupka, F. J. (2013). The impact of price and tobacco control policies on the demand for electronic nicotine delivery systems. Tobacco Control, 23, iii41–iii47.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
10
Evaluation & the Health Professions
Kamerow, D. (2014). The battle between big tobacco and vape shops. British Medical Journal, 349 (published online September 26, 2014). Klein, K. E. (2013). Health markups on e-cigarettes turn vacant storefronts into ‘vape shops’. Bloomberg Businessweek. Retrieved December 20, 2013, from http://www.businessweek.com/articles/2013-10-03/healthy-markups-on-e-cigarettesturn-vacant-storefronts-into-vape-shops Lee, Y. O., & Kim, A. E. (2014). ‘Vape shops’ and ‘E-cigarette lounges’ open across the USA to promote ENDS. Tobacco Control (published online April 11, 2014). Lechner, W. V., Tackett, A. P., Grant, D. M., Tahirkheli, N. N., Driskill, L. M., & Wagener, T. L. (2015). Effects of duration of electronic cigarette use. Nicotine & Tobacco Research, 17, 180–185. Marynak, K., Holmes, C. B., King, B. A., Promoff, G., Bunnell, R., & McAfee, T. (2014). State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems—United States, November 2014. Morbidity and Mortality Weekly Report (MMWR), 63, 1145–1150. McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014. Art. No.: CD010216. doi:10.1002/14651858.CD010216.pub2 Meier, E., & Wagener, T. L. (2014, Summer). More frenemy than enemy. The Addictions Newsletter: Division 50 of the American Psychological Association, 21 (2), 19–21. Pearson, A. (2014, September). Local strategies to regulate vape shops & lounges. Oakland, CA: ChangeLab Solutions. Retrieved from http://changelabsolutions. org/sites/default/files/Vapor_Lounges_FINAL_20140926_1.pdf Polosa, R., Caponnetto, P., Cibella, F., & Le-Houezec, J. (2015). Quit and smoking reduction rates in vape shop consumers: A prospective 12-month survey. International Journal of Environmental Research and Public Health, 12, 3428–3438. Sussman, S., Garcia, R., Cruz, T. B., Baezconde-Garbanati, L., Pentz, M. A., & Unger, J. (2014). Consumers’ perceptions of vape shops in Southern California: An analysis of online Yelp reviews. Tobacco Induced Diseases, 12, 9. U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the surgeon general. Rockville, MD: U.S. DHHS, United States Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Office on Smoking and Health (OSH). Zhu, S.-H., Sun, J. Y., Bonnevie, E., Cummins, S. E., Gamst, A., Yin, L., & Lee, M. (2014). Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tobacco Control, 23, iii3–iii9.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Commentary: Forces That Drive the Vape Shop Industry and Implications for the Health Professions
Evaluation & the Health Professions 1-10 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0163278715586295 ehp.sagepub.com
Steve Sussman1,2,3, Lourdes Baezconde-Garbanati1,4, Robert Garcia1, Dianne C. Barker5, Jonathan M. Samet1, Adam Leventhal1,2, and Jennifer B. Unger1
Abstract At least three factors may be driving the evolution of the vape shop industry, a rapidly growing market sector that specializes in the sales of electronic cigarettes: (1) the tobacco industry, (2) the public health sector and its diverse stakeholders, and (3) consumer demand. These influences and the responses of the vape shop sector have resulted in a rapidly
1
Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA Department of Psychology, University of Southern California, Los Angeles, CA, USA 3 School of Social Work, University of Southern California, Los Angeles, CA, USA 4 Department of Sociology, University of Southern California, Los Angeles, CA, USA 5 Barker Bi-Coastal Health Consultants, Inc., Calabasas, CA, USA 2
Corresponding Author: Steve Sussman, Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA. Email: [email protected]
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
2
Evaluation & the Health Professions
changing landscape. This commentary briefly discusses these three factors and the implications for the health professions, as they address the vape shop industry and its consequences for public health. Keywords vape shops, electronic cigarettes, health
Electronic cigarettes or e-cigarettes are battery-powered devices that are used to vaporize a propylene glycol (PG) and/or vegetable glycerin (VG) solution, generally with some type of flavoring, and which may also contain liquid nicotine in various concentrations. There are also e-cigarettes that do not contain nicotine. E-cigarettes may be disposable (e.g., Blu and Njoy disposable brands often sold at convenience stores) or rechargeable (with battery chargers, heating coils, and liquid solution). E-cigarette users (often called ‘‘vapers’’) inhale a vapor that does not contain many of the toxic compounds in cigarette smoke generated by combustion that contribute to the extremely high risk of disease and premature death in smokers (Sussman et al., 2014). In the last few years, ‘‘vape shops’’ have proliferated in various countries, including the United States (retrieved April 19, 2015, from http://www.bloomberg.com/bw/articles/2013-10-03/healthymarkups-on-e-cigarettes-turn-vacant-storefronts-into-vape-shops). These shops are so named because they specialize in the sales of e-cigarette products. There are at least 3,500 vape shops in the United States (Klein, 2013; Lee & Kim, 2014), though estimates of 6,000–7,000 (retrieved April 19, 2015, from http://vapenewsmagazine.com/november-2014/ how-many-vape-shops-are-there-in-the-u-s-a) and as high as 35,000 shops have been made (Kamerow, 2014). Unlike other retailers, most vape shops allow users to sample several types of electronic juices (e-juices), mostly using rechargeable devices. Vape shops sell a variety of types of refillable (and, rarely, disposable) e-cigarettes, several types of solution strengths and flavors, more complex and powerful tank systems that offer customized vaping experiences for experienced users, and sometimes other accessories (e.g., T-shirts). The vape shop business visibility is rapidly increasing. For example, a Google search for ‘‘vape shops’’ with ‘‘Los Angeles’’ revealed over 5,000 pages (retrieved December 20, 2013), which increased to over 88,300 pages in 16 months (retrieved April 15, 2015). The markup on e-cigarettes can be 200–400% (compared to 10–20% for combustible cigarettes), which may
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
3
account for the unprecedented growth in the prevalence of such shops (Klein, 2013; Lee & Kim, 2014), with total e-cigarette sales worldwide being over US$3.5 billion (retrieved April 19, 2015, from http://www.reuters.com/ article/2014/09/12/us-tobacco-ecigarettes-insight-idUSKBN0H711I20140912). Sales of e-cigarette products in vape shops likely are quite high, although traditional measures (e.g., the Nielsen Company) have not included vape shops yet as retailers (Giovenco, Hammond, Corey, Ambrose, & Delnevo, 2015). It is not yet possible to accurately calculate the price elasticity of vape shop–related vaping (Huang, Tauras, & Chaloupka, 2013), and the future growth of vape shops is uncertain (retrieved April 19, 2015, from http://ecigone.com/featured/future-history-e-cigarette-industry/). The proliferation of vape shops ultimately may have a negative impact on health behaviors and health outcomes. E-cigarettes when heated may generate carcinogenic components in the vapor, the production and composition of flavorings are not regulated, and nicotine itself is addictive, may raise blood pressure, and has deleterious effects on youth and on the fetus during pregnancy (Chapman, 2015; Grana, Benowitz, & Glantz, 2014; U.S. Department of Health and Human Services, 2014). Spills and lack of other safety precautions such as not wearing gloves or goggles while handling juices, or liquid nicotine, or while drilling air holes or rebuilding, at the vape shops may also cause risks to workers and patrons through suffering nicotine toxicity and other effects of coming into contact with e-juice (Pearson, 2014). Also, to the extent that purchasers do not use e-cigarettes to stop smoking traditional, combustible cigarettes but instead use them along with combustible cigarettes (dual use) to remain nicotine dependent, these shops may indirectly promote continued use of a variety of tobacco and nicotine-containing products (Grana et al., 2014). Empirical and theoretical studies regarding this alternative market are now only beginning to be published, which generally involves nicotine delivery. Even as descriptive articles are being published, the vape shop enterprise is a very dynamically changing context right now. In the present commentary, we describe three factors that appear to be driving the evolution of the vape shop industry. First, the vape shop industry appears to be offering an alternative market to that of the tobacco industry. That is, vape shops offer an alternative product to combustible tobacco, the latter long being the mainstay of the tobacco industry. Second, the public health community and its stakeholders are responding to the emergence of e-cigarettes vigorously but with diverse views. For
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
4
Evaluation & the Health Professions
some stakeholders in the public health and medical professions, the vape shop industry offers a product that is viewed as valuable for harm reduction, whereas others are concerned that wide availability of ecigarettes, particularly with flavorings, may promote nicotine addiction among youth and lead to dual use. Third, there is an appeal of the product to customers and a demand for better and less expensive products. In this commentary, we describe these factors, suggest ways that the vape shop industry is responding, and address some implications for the health professions.
Tobacco Industry The relationship between the vape shop industry and the tobacco industry is adversarial in general, besides the presence of some ‘‘vape and smoke’’ shops that, anecdotally, are rejected by a majority of the vape shop industry. Most vape shops do not sell disposable or rechargeable brands that are owned by ‘‘Big Tobacco’’ companies, such as Blu (owned by Lorillard), Vuse (owned by R. J. Reynolds), and MarkTen (owned by Altria), preferring to stock products that are manufactured independently of tobacco industry influence (Kamerow, 2014). The tobacco industry is responding to this stance. Recently, Reynolds American filed a 119-page submission to the Food and Drug Administration (FDA) to ban the use of opensystem vapor e-cigarettes, which may interfere with vape shop practices (retrieved April 16, 2015, from http://www.journalnow.com/business/business_news/local/reynolds-american-wants-fda-to-ban-vapor-e-cigs/article_ 77b131f5-540d-5f02-927c-733bac751529.html). The reaction of the vape shop industry to such tobacco industry actions has been to claim that the tobacco industry is trying to stop competition. Vape shop owners in general continue to not sell tobacco industry items and publically express fear or distrust of the tobacco industry. Anecdotally, electronic cigarettes are starting to be referred to more as ‘‘personal electronic vaporizing units’’ in shops, in part, to dissociate them from combustible ‘‘cigarettes’’ (retrieved April 20, 2015, from http://sfata.org/blog/front_tabs/product-design/). In addition, pro-vaping activism groups such as Consumer Advocates for Smokefree Alternatives Association (CASAA) have exerted their own efforts to influence decisions that might be made by the FDA (retrieved April 17, 2015, from see http://blog.casaa.org/2015/04/call-to-action-submitcomments-on-fdas.html).
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
5
Public Health Sector and Its Stakeholders A second source of pressure comes from the public health sector and their stakeholders (e.g., local governments and nonvapors). With the assumption that e-cigarettes may be dangerous to users and persons exposed to vapor (e.g., nicotine itself has negative consequences, some flavorings are dangerous, such as diacetyl, and there may be dangers of PG and VG released in vapor aerosol; see Grana, Benowitz, & Glantz, 2014), restrictions on the number and location of vape shops, types and content of e-juices, and ability to vape within shops are being considered at the local level. While there is some debate, in general, the public health sector is hesitant to recommend e-cigarettes as a means to quit combustible cigarettes (e.g., Ebbert, Agunwamba, & Rutten, 2015), and calls for the regulation of e-cigarettes have been made that explicitly mention vape shops as a distribution channel (e.g., Brandon et al., 2015; Digulio, 2015). Speaking as chief of the California Department of Public Health, Chapman (2015) mentioned that ecigarettes emit at least 10 chemicals on California’s Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive harm. He further asserted an urgent need for education about e-cigarettes, protection of minors, application of all combustible cigarette policies to ecigarettes, and protections to the general population from e-liquids and ecigarette-related aerosols. Likewise, Grana, Benowitz, and Glantz (2014) made policy recommendations including prohibiting the use of e-cigarettes anywhere that the use of combustible cigarettes is prohibited (e.g., as operates in North Dakota, New Jersey, and Utah; partial restrictions exist in 18 states; American Nonsmokers’ Rights Foundation [ANRF], retrieved April 30, 2015, from http:// www.no-smoke.org/pdf/ecigslaws.pdf), prohibiting the sale of e-cigarettes to anyone who cannot legally buy cigarettes or in any venues where the sale of combustible cigarettes is prohibited, subjecting e-cigarette marketing to the same level of restrictions that apply to combustible cigarettes (including no television or radio advertising), prohibiting co-branding e-cigarettes with combustible cigarettes or marketing in a way that promotes dual use, prohibiting the use of characterizing flavors in e-cigarettes (particularly candy and alcohol flavors and flavors that would be attractive to youth), prohibiting claims that e-cigarettes are effective smoking cessation aids until e-cigarette companies provide sufficient evidence that e-cigarettes can be used effectively for smoking cessation, prohibiting any health claims for e-cigarette products until unless approved by regulatory agencies as meeting scientific standards, and establishing standard policies for regulating the
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
6
Evaluation & the Health Professions
ingredients of any tobacco-derived nicotine containing product. A proposed ‘‘deeming rule’’ (see 21 Code of Federal Regulations Parts 1100, 1140, and 1143) may facilitate these policies being set in place (retrieved April 15, 2015, from, http://www.fda.gov/TobaccoProducts/Labeling/ucm388395.htm). Also, consequently, local government city councils and nonvape shop business owners have petitions under review to prohibit vape shops in their jurisdictions (e.g., in Highland Park, Long Beach, Monterey Park, and Pasadena, California). Conversely, the European Commission proposed some regulations that would permit e-cigarettes to be viewed as medications useful to wean one off of combustible cigarettes (retrieved April 16, 2015, from http://www.economist.com/news/leaders/21586855european-lawmakers-should-reject-proposals-control-electronic-cigarettesstrictly). The vape shop industry has been responding to these public health measures. Responses are provided on vape shop-related websites as well as informally among vape shop owners and customers. For example, one wellknown website (retrieved April 16, 2015, from http://www.e-cigarette-forum.com/forum/) discusses in a forum format (a) e-cigarette legislation at the U.S. federal and state level, (b) FDA regulations and proposals including the deeming rule, (c) European Union legislation, (d) campaigning ideas to support e-cigarette use, (e) local laws on sales of e-cigarettes, (f) CASAA forum, and (g) Electronic Cigarette Consumers Association of the United Kingdom (ECCA UK), the U.K. consumer association forum. Another anecdotal example, after some recent instances of nicotine poisoning among infants (e.g., Bassett, Osterhoudt, & Brabazon, 2014), the vape shop industry has responded with increasing use of child safety caps on e-liquid bottles, as well as safety warnings and ingredient listings on e-juice bottles. The vape shop industry also keeps abreast of scientific research that supports cessation of combustible cigarettes through vaping (e.g., retrieved April 19, 2015, from http://www.ecigarette-research.com/web/index.php). One recent research study of 71 adult (mean age ¼ 41) combustible cigarette smokers in Sicily who went to vape shops to quit combustible cigarettes showed a 41% intent-to-treat (ITT) combustible cigarette quit rate 12 months after beginning vaping (Polosa, Caponnetto, Cibella, & LeHouezec, 2015). While there was no comparison group and the sample was one of convenience, these results were promising in terms of vapor e-cigarettes serving as a means of cessation from combustible cigarettes. This article is likely to appear on vaping forums soon along with some others that indicate decrease in the use of combustible cigarettes along with an increase in the use of e-cigarettes among adults recruited in vape shops
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
7
(Berg, Barr, Stratton, Escoffery, & Kegler, 2014 [23% ITT quit rate]; Lechner et al., 2015; McRobbie, Bullen, Hartmann-Boyce, & Hajek, 2014; Meier & Wagener, 2014), although the quality of available empirical work generally is low and not all published work demonstrates relatively greater cessation among those using e-cigarettes compared to nonvaping controls (see Grana et al., 2014).
Consumer Demand The third source of pressure is customer demand. Sussman et al. (2014) conducted a Yelp electronic search and content analysis of consumer reports concerning vape shops that they have visited. The primary measure was Yelp reviews (N ¼ 103 vape shops in the Los Angeles, California area), which were retrieved and content coded. They compared the attributes of vape shops representing four ethnic communities, African American, Hispanic/ Latino, Korean, and White and found that vape shop attributes listed as most important were the selection of flavors or hardware (95%), fair prices (92%), and unique flavors or hardware (89%). Relatively few of the reviews mentioned quitting smoking (32%) or safety of e-cigarettes (15%). Thus, consumers appear to desire more efficient, practical, low-cost vaping devices and an ever-increasing variety of types of vapor devices and flavors. Notably, based on an extensive search of electronic websites, Zhu et al. (2014) reported that there were 466 brands of e-cigarettes and 7,764 e-juice flavors at that time. Currently, a new box-type modular device (box mod e-cigarette), which permits regulating ohms (resistance) through use of a memory chip and is increasingly affordable, is taking the place of tubular, more inefficient devices (retrieved April 12, 2015, from http://www.vaporizerviews.com/ box-mods/). Anecdotally, the availability of vape magazines that appear in shops (e.g., VPR; retrieved April 20, 2015, from https://www.vprmag.com/), ‘‘cloud chasing’’ contests, televisions, and sometimes food and beverages, and couches appear to provide a means of having patrons spend time in the shops as well as consume products (e.g., Sussman et al., 2014). Certainly, store owners perceive e-cigarettes as much more safe than combustible cigarettes, offer sophisticated marketing approaches including loyalty point incentives for customers, and make vape shops an environment in which customers can socialize (e.g., Cheney, Gowin, & Wann, 2015; Sussman et al., 2014). In summary, in order to maintain and increase revenue streams as well as to provide a useful service to their customers, vape shops are motivated to respond to pressures from their consumers—pressures that are rapidly changing.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
8
Evaluation & the Health Professions
Conclusions: Implications for the Health Professions Tracking of vape shops is needed to inform future regulations, educate the health professions about similarities and differences between vape shops and traditional tobacco retail outlets (e.g., convenience stores) predominately selling disposable e-cigarettes, and assist persons in the health professions to decide how to advise their patients who want to quit smoking combustible cigarettes. Learning more about the physical environment of vape shops, as well as about the products sold, provides a ‘‘big picture’’ of marketing strategies to understand what may lead consumers to initiate and maintain a vaping habit (e.g., Sussman et al., 2014) and possibly help combustible tobacco smokers wanting to quit who have not been successful with existing evidence-based cessation products. Potential for long-term dual use of combustible and e-cigarettes, and to ‘‘hook’’ nonsmokers who otherwise might avoid nicotine addiction, needs highlighting. A greater understanding of how minors’ access laws (now in place in 42 states and one territory; retrieved April 20, 2015, from http://www.ncsl.org/ research/health/alternative-nicotine-products-e-cigarettes.aspx; also see Marynak et al., 2014), and safety precautions for e-juice production, are being voluntarily enforced by vape shops is warranted. At this time, it appears that several health experts see the promise of e-cigarettes as a means of cessation for longtime adult combustible cigarette smokers. However, more research is needed. Among other issues is that, in many shops, vape shop clerks are being put in the role of smoking cessation counselors, probably with minimal training. Tentatively, training of vape shop employees in evidence-based smoking cessation techniques including how best to help customers eventually titrate down to zero nicotine liquids and possibly, eventual abstinence, if desired, is recommended. However, additional research is needed on how to implement this strategy. Vape shops will undoubtedly continue to evolve, given the forces that we described. While the long-term impact of vape shops on the public health is yet to be determined, we contend that understanding the various sources of influence on vape shop practices will be important for developing and implementing public health surveillance and policies that address this critical segment of the nicotine marketplace. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
Sussman et al.
9
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by grant number DA020138 from the National Institute on Drug Abuse and by grant number P50CA180905 from the National Cancer Institute and Food and Drug Administration (FDA) Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.
References Bassett, R. A., Osterhoudt, K., & Brabazon, T. (2014). Nicotine poisoning in an infant. New England Journal of Medicine, 370, 2249–2250. Berg, C. J., Barr, D. B., Stratton, E., Escoffery, C., & Kegler, M. (2014). Attitudes toward e-cigarettes, reasons for initiating e-cigarette use, and changes in smoking behavior after initiation: A pilot longitudinal study of regular cigarette smokers. Open Journal of Preventive Medicine, 4, 789–800. Brandon, T. H., Goniewicz, M. L., Hanna, N. H., Hatsukami, D. K., Herbst, R. S., Hobin, J. A., . . . Warren, G. W. (2015). Electronic nicotine delivery systems: A policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology. Journal of Clinical Oncology, 33, 952–963. Chapman, R. (2015). State health officer’s report on e-cigarettes: A community health threat. Sacramento: California Department of Public Health, California Tobacco Control Program. Cheney, M., Gowin, M., & Wann, T. F. (2015). Marketing practices of vapor store owners. American Journal of Public Health (published online April 16, 2015), e1–e6. Digulio, S. (2015). AACR and ASCO jointly call for federal regulation of e-cigarettes. Oncology Times, 37, 28–29. Ebbert, J. O., Agunwamba, A. A., & Rutten, L. J. (2015). Counseling patients on the use of electronic cigarettes. Mayo Clinic Proceedings, 90, 128–134. Giovenco, D. P., Hammond, D., Corey, C. G., Ambrose, B. K., & Delnevo, C. D. (2015). E-cigarette market trends in traditional U.S. retail channels, 2012– 2013. Nicotine & Tobacco Research (published online January 15, 2015). Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: A scientific review. Circulation, 129, 1972–1986. Huang, J., Tauras, J., & Chaloupka, F. J. (2013). The impact of price and tobacco control policies on the demand for electronic nicotine delivery systems. Tobacco Control, 23, iii41–iii47.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
10
Evaluation & the Health Professions
Kamerow, D. (2014). The battle between big tobacco and vape shops. British Medical Journal, 349 (published online September 26, 2014). Klein, K. E. (2013). Health markups on e-cigarettes turn vacant storefronts into ‘vape shops’. Bloomberg Businessweek. Retrieved December 20, 2013, from http://www.businessweek.com/articles/2013-10-03/healthy-markups-on-e-cigarettesturn-vacant-storefronts-into-vape-shops Lee, Y. O., & Kim, A. E. (2014). ‘Vape shops’ and ‘E-cigarette lounges’ open across the USA to promote ENDS. Tobacco Control (published online April 11, 2014). Lechner, W. V., Tackett, A. P., Grant, D. M., Tahirkheli, N. N., Driskill, L. M., & Wagener, T. L. (2015). Effects of duration of electronic cigarette use. Nicotine & Tobacco Research, 17, 180–185. Marynak, K., Holmes, C. B., King, B. A., Promoff, G., Bunnell, R., & McAfee, T. (2014). State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems—United States, November 2014. Morbidity and Mortality Weekly Report (MMWR), 63, 1145–1150. McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014. Art. No.: CD010216. doi:10.1002/14651858.CD010216.pub2 Meier, E., & Wagener, T. L. (2014, Summer). More frenemy than enemy. The Addictions Newsletter: Division 50 of the American Psychological Association, 21 (2), 19–21. Pearson, A. (2014, September). Local strategies to regulate vape shops & lounges. Oakland, CA: ChangeLab Solutions. Retrieved from http://changelabsolutions. org/sites/default/files/Vapor_Lounges_FINAL_20140926_1.pdf Polosa, R., Caponnetto, P., Cibella, F., & Le-Houezec, J. (2015). Quit and smoking reduction rates in vape shop consumers: A prospective 12-month survey. International Journal of Environmental Research and Public Health, 12, 3428–3438. Sussman, S., Garcia, R., Cruz, T. B., Baezconde-Garbanati, L., Pentz, M. A., & Unger, J. (2014). Consumers’ perceptions of vape shops in Southern California: An analysis of online Yelp reviews. Tobacco Induced Diseases, 12, 9. U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the surgeon general. Rockville, MD: U.S. DHHS, United States Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Office on Smoking and Health (OSH). Zhu, S.-H., Sun, J. Y., Bonnevie, E., Cummins, S. E., Gamst, A., Yin, L., & Lee, M. (2014). Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tobacco Control, 23, iii3–iii9.
Downloaded from ehp.sagepub.com at University of Otago Library on November 15, 2015
