The regulatory shift in favor of flavored nicotine pouches and vapes took a strong new turn yesterday, as the FDA allowed 20 Zyn products to be marketed as less harmful than cigarettes.

Why it matters: The designation could increase the use of "modified risk products" among adult smokers but also boost their appeal to young people.

• More than 9 out of 10 youths who used nicotine pouches opted for mint, fruit and other flavors, according to the latest National Youth Tobacco Survey.

Driving the news: The FDA allowed 10 Zyn flavors in 3- and 6-milligram strengths to be marketed with the claim that "using ZYN instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis," Axios first reported.

• That's a win for Philip Morris International, the parent company of Zyn manufacturer Swedish Match, which has argued that adult smokers need accurate information about the relative risks of different products.

It was the latest in a series of favorable FDA decisions on flavored vapes and pouches.

• In May, the agency authorized its first fruit-flavored vaping products for adults. It also allowed certain unapproved e-cigarettes and pouches to remain on store shelves if manufacturers have a pending application.

What they're saying: "It is appalling that the FDA would authorize flavors like citrus, cool mint and cinnamon as modified risk tobacco products, which attract kids," said Mike Seilback, an American Lung Association assistant vice president.

The other side: The decision ensures that adult smokers "have access to accurate, science-based information, including FDA-authorized evidence that switching from cigarettes to ZYN reduces the risk of smoking-related diseases like heart disease and lung cancer," said Stacey Kennedy, Philip Morris' U.S. CEO.

What we're watching: Whether people who try to quit smoking by using other tobacco products end up using both at the same time — or whether use of alternative products is dominated by people who weren't formerly smokers.

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An influential conservative think tank is issuing a new call for policy changes that would lower the federal government's health care spending, including several that would be guaranteed to generate political blowback.

Why it matters: Paragon Health Institute has considerable sway with congressional Republicans and the Trump administration, both in terms of proposing policies and serving as a springboard for key staffers.

• Even though Republicans may lose one or both chambers of Congress in the midterm elections, the Paragon worldview is likely to remain highly relevant for the remainder of the Trump administration.

The big picture: The very design of federal health care programs — including Medicare, Medicaid and the Affordable Care Act — incentivizes waste and higher health care prices, Paragon CEO Brian Blase wrote in a paper provided first to Axios.

• Most of the policy changes Paragon calls for are highly partisan, and nearly all of them would draw fierce criticism from the health care industry.
• But some of the topics Paragon takes aim at — including Medicare Advantage, hospital payment policies and the ACA's medical loss ratio — have also attracted scrutiny from Democrats or their allies and could be the basis for bipartisan policymaking in the next Congress.

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Doctors are reporting new shortages of widely used generic cancer drugs, prompting fears that some treatments will need to be delayed or rationed.

Why it matters: The shortage is reminiscent of a cancer drug crisis three years ago that affected oncology patients' ability to get timely access to chemotherapies.

• While experts say the current shortages could resolve more quickly, they say the situation still highlights the continued fragility of the supply chain for critical generic medicines.

Driving the news: Physicians at NYU Langone's Perlmutter Cancer Center have been regularly reviewing whether some patients have to stick with the standard treatment or whether they could tolerate alternatives, Naomi Ko, section chief for breast medical oncology, told Axios.

• "I don't want to have to tell patients I have to be creative because I just can't get the drug I actually prefer because it's an older drug and they aren't producing it anymore," Ko said.

By the numbers: Hospital fill rates — reflecting how much of a drug order is received — fell to 66% for cisplatin in June, according to group purchasing organization Premier.

• It considers a fill rate of less than 80% a "danger zone." Cisplatin is an injectable used for advanced cancer of the bladder, ovaries or testicles.
• The fill rate for ifosfamide — used to treat lymphoma, sarcoma, and lung cancer — fell even further to 37%.

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🇨🇳 A congressional panel opened an inquiry into Bristol Myers Squibb and Pfizer's use of clinical trial sites in China, including facilities allegedly linked with the Chinese military. (Endpoints)

🏛️ Rep. Tom Kean (R-N.J.) said he missed nearly four months of votes because of a depression diagnosis, ending speculation over one of the longest absences by a member. (Axios)

🧬 The FDA is losing another top drug reviewer in Vijay Kumar, who plans to step down as acting director of the office of gene and cell therapy reviews. (Biopharma Dive)

🌞 The FDA just approved its first new active sunscreen ingredient in 20 years. Instead of using it, many Americans are "tanmaxxing." (Axios)