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Teen Vaping: the wrong target to justify banning flavours in e-cigarettes: A reply to the Quebec Ministry of Health report

Jocelyn M.

发布日期: 2020年12月12日

In light of a report submitted by the Ministry of Health on electronic cigarettes (e-cigs), as well as a press release from CQCT that followed, we feel it necessary to bring forth clarifications on many elements presented and that we feel require corrections

As did the Ministry of Health and the CQCT, we express a strong position against any form of tobacco or tobacco-related products in teens, young adults as well as non-smokers. Our position is that a good smoker is a non-smoker or at least one in the making. In achieving such goal, for too many, as the actual pharmacological options now available have failed them badly (nicotine replacement therapy (NRT), varenicline, or bupropion among others), it appears that the usage of e-cigs does emerge as an option with a level of efficacy that is appealing to many. A study published in the NEJM 1 on 886 smokers showed that e-cigs could offer a doubling of the efficacy compared to pharmacological options while reducing adverse effects, as well as coughing related to cigarette usage. So much more trials have been published that it pushed the gold standard of evidence-based medicine, Cochrane, to publish in October, a review of 14,430 individuals which lead to a positioning statement on the usage of e-cigs as a clinically relevant smoking cessation option 2, as it increases by 40% any probability of smoking cessation compared to pharmacological options. Since then, a real-world evidence analysis 3 confirmed the high level of efficacy of e-cigs, of 93% as a single therapy, vis a vis 49% for NRT and 57% for varenicline. All of this while offering a 95% reduction of exposure to cigarettes toxicants 4, through the elimination of combustion, a situation that the latest UK COT 5 report confirms even more.

For 93% of smokers, flavours other than tobacco represent the first option in smoking cessation choice 6 in their objective towards such a goal. Underlying motivations 7 in choosing such options are a willingness to reduce dependency on cigarettes and stopping smoking, followed by a c more convenient option in use. But factors related to the failure of such an option were a failure to achieve similar satisfaction to cigarettes (cigs) et the inability to eliminate the craving towards cigs. Therefore, removing flavours, at least in full, would put at risk may individuals in their willingness to no longer smoke. Despite a full removal from the market, the true extent of such might be tampered by the readily availability of alternatives either in source or products, either via the internet or illicit sources of such products 8. In a situation of such ban, up to 27.5% of teens surveyed 8 were able to obtain products without age verification and without quality control of such products. Should one be reminded of the danger of such a situation with the EVALI crisis that leads to many deaths in both the USA and Canada, where THC laced with vitamin E acetate caused this THC-VALI syndrome? Of note that no death was linked to legally produced or sold products during such period. Therefore, any form of prohibition and ban of flavours would constitute a mistake 9. Indeed, when looking at factors related to the initiation of vaping, flavours are far from being the most significant drivers: curiosity and peer pressure are stated as the most important drivers of e-cigs usage 10,11, but this peer pressure could also be linked to the cessation of usage 12. That parents would be users is also a significant driver towards the usage of e-cigs 13,14. Creating a safe zone around and in schools is key as such e-cigs usage around such is a described issue in this European study 15.

A number of medical societies have expressed statements against the use of e-cigs 16,17, position in total opposition with either the latest Cochrane Review on e-cigs 1 as well as the Public Health England/UK stance of the benefit of e-cigs18. While many literature reviews have tried to link an enhanced risk on either respiratory or cardiovascular function, this latest systematic review 19 of 6 studies with populations ranging from 19,475 to 161,529 individuals showed a totally different situation. This study showed a significant reduction of respiratory risks as described as COPD, chronic bronchitis, emphysema, and wheezing in smokers that have switched away from cigs to e-cigs. The extent of the changes was between 32 to 42% (HR0.58 to 0.66, p<0.05). A study with a 3-year follow-up 20 showed that the beneficial effects could be a reversal of the negative effects of years of smoking in former smokers facing COPD, with now 5 years maturity data 21 with ongoing benefits in these patients. On the cardiovascular side 19, e-cigs were demonstrated as not introducing any more risk as defined as stroke, myocardial infarction, or coronary heart disease. This data fully contradicts a paper from Glantz et al 22, a biased study that linked myocardial infarction that happened prior to any e-cigs usage to such product. Rodu et al 23 were able to show the fallacious conclusions, both in facts and underlying hypothesis 24, to this extent that is forced this paper to be retracted. Still, despite such retractation, too many revue articles, and position statements from medical societies are still referring to such retracted paper 24, an important flaw. A further study 25 was able to show that e-cigs by no mean would negatively affect cardiovascular effects, over a 24 hours evaluation compared to cigs. Another study showed that a switch from cigs to e-cigs would translate into an improvement in endothelial function, with significant effects on vascular stiffness as well 26.

On the aspect of teen e-cigs usage, while many have been trying to demonstrate a gateway effect towards cigs, and with such a nicotine dependence, but such has rarely described nor demonstrated. An American review 27 of pediatric emergency visits showed that only 0.4% of such were related to nicotine usage dependency (15,376 of 3,963742 visits). Also, in the USA, an interesting approach of intervention 28 with parents of children at the pediatric was done in discussing potential smoking cessation at such a moment. Such intervention of about 100$ could lead to parents stopping smoking and ultimately have the positive impact of not having a smoking parent as a model towards the same pathway. This intervention is one that any pediatrician or family physician should foster and discuss as an option to positively reduce smoking in houses where children are living. T21 legislations 29 restricting access to e-cigs or tobacco in minors below the age of 21 was proven to be the most efficient approach to reduce risks of smoking products being acquired by these teens.

Many have hypothesized that a gateway from e-cigs to cigs would exist in teens. A number of cohorts from the USA have shown a totally different situation, with accelerated drops in cigs usage since the introduction of e-cigs. Analysis in such cohorts 30 showed that 90.7% of teens having used e-cigs will never use cigs later, but 69% of cigs users would continue to smoke such cigs. Another cohort 31 of half a million teens pointed to a rise in vaping between 2011-19 specifically in younger boys, with significant drops in smoking from 1991 to 2019. The PATH study 32 through the analysis of its third wave showed that e-cig usage had no effect on either increases or reduction of tobacco usage in young adults. A Canadian study 33 from Dr. Hammond looking at both a USA, UK and Canadian cohort of teens from 16 to 19 showed that 5.7% of teens were vaping, with 20.4% of such, i.e 1.2% of the total cohort were regular users, and most likely former smokers, 66.5% of these vapers namely 3.8% were occasional users. Of all of the surveyed teens, only 0.8% of the entire cohort (13.1% of the 5.7% being vapers) were teens that have never used either vaping or tobacco products. Such data do demonstrate that the gateway risk is very low with less than 1% of vaping to cigarette transition 33, with less than 0.4% 26. It, therefore, seems that some form of teen training sessions on nicotine at the school level would be of interest 34, at the same time the same form of school curriculum on all types and aspects of dependency should be target teens.

In assessing the underlying motivations pushing teens towards e-cigs, multiple studies showed that curiosity was the key driver 35, along with appetite control, mood stabilization, misbeliefs that appropriate information/ training sessions should be able to dissipate. A phenomenon of a transitory usage of e-cigs now has emerged in young adults 35, with curiosity being the driver in the first year of college with a 35% usage as experimentation, dropping to 19% in the second year of college, evidence of a step towards a smoking arrest. More specifically in the case of JUUL 36, this novel device for vaping, in a college setting, a significant drop in usage was seen through college years and age. So far, the gateway theory remains only a theory 37, and only a full analysis of all tobacco products over time would be the only way to demonstrate any of such gateway effect. The most recent Canadian numbers 33 of a 2019 tobacco analysis of usage pointed to the acceleration smoking reduction, this despite this curiosity of teen towards vaping 38. The challenges of a full demonstration of a gateway would require asking the right question as per usage 39, the same issue one sees in assessing smoking cessation: curiosity towards e-cigs is not dependence of it, and trying does not mean adopting this as a new addiction/habit. Also, some very intriguing data came from a study 40 that showed that e-cigs usage in teens could even lead to a reduction in further smoking of cigs, by a 2.5 fold benefit, and in reducing a 50% of cigs usage by 2.36 fold in teens using both tobacco and alcohol 41. Of even more interest was this French study 42 where having vaped as a teen could reduce the potential of smoking by 42% (HR 0.58), a benefit even greater in cases of late experimentation (age 17) compared to an early trial (age 9). It appears from a college assessment of e-cigs that dependency was not linked to having tried e-cigs a few times, but when such reached a threshold of 50 usages 35, the risk of dependency was increasing. Again, experimentation does not lead to de facto adoption and transition to cigs.

We will need to balance the emerging and confirmed benefits of e-cigs in smoking cessation in adults with the concern but absence of significant data on the gateway effect of e-cigs, especially in light of important reductions in smoking in teens and young adults 43 and that increases in e-cigs are translating into tangible effect between 2011 and 2019, raising the question as to the reality of e-cigs most likely as experimentation and a fad 31. Denying these impacts in the adult smoking population may constitute a dangerous avenue for public health as described by Iowa`s AG 44, stating that some have wrongly demonized e-cigs, make this gateway theory a reality that it is not, and have misinformed on the importance and positive effects of e-cigs in adult smoking cessation. This Australian model 45 has demonstrated the potential impacts of e-cig, with a 21% reduction of smoking-related deaths, with a 20% reduction of years of life lost due to smoking.

We also need to give adults surrounding our youth tools so they could identify the potential risk of addiction under any type or form 46, one being pressure from peers as well as parent absence or detachment. Indeed, other addictions beyond e-cigs are far more worrisome, and important in numbers, such as abuse of alcohol 47 and cannabis 48, where, here too, peer pressure plays a role, as would a more liberal approach of parents towards these two, and a more readily and accessible. These are three elements that the liberalization of cannabis has enhanced in Canada. Alcohol abuse should be high on our radar, present in one-third of teen suicide 49, illicit substances in 28.1% in an Australian study. Giving these adults the tools to identify risk factor is key as physical abuses were described in 7.4% of such suicides, the presence of diagnosed mental illnesses in 40.9% with some underlying mental issues in 15.7%, all being things that we should be able to identify before this terrible outcome of suicide. But how are we helping parents, teachers and other adults involved with teens in looking for such issues is a key question. Also, in light of the risk that ADHD represents on subsequent addiction risks 50, early identification of this is key. The role of parents 51 is also crucial as a firmer approach towards these reduces the usage of both tobacco and cannabis but not alcohol. Our society has made the decision to decriminalize cannabis but such a product has known gateway effects towards e-cigs 52, which pushes us to make sure that teens cannot buy such products in stores providing these to adults.

On the taxation side, rather than imposing more of these on tobacco products or alternatives, other options could be considered. Such an avenue has the risk to push vapers back into smoking 53 . We are expressing concerns that it would be smokers are individuals of poor socioeconomic status, and that would try to quit such addiction. A significant increase of taxes on these already monetary stressed individuals can further affect these, as is the example of Arkansas where a smoker may spend as much as 15% of his revenues on both cigarettes and the taxes related to such 54. Tobacco is such an important issue in our society, and treating it, coverage through national programs of smoking cessation approaches is paramount, and e-cigs could and should be covered. The E3 55 study could be an interesting model of integration of e-cigs into a smoking cessation program.

Finally, we should discuss a potential limitation of nicotine levels presented by the Ministry of Health. While many countries or provinces have put forth a 20mg/mL threshold, studies 56 have raised questions around such limitations, as many smokers complained of not finding sufficient satisfaction compared the cigarette of their past. As this represent one of the key factors for e-cigs failure 7, it could be appropriate to offer higher levels in cases where the lower levels do present an issue for some. While many have expressed concern around abuse on such higher levels, data shows that such is not the case: users of JUUL 3.0%: 35mg/mL or even 5.0%: 59mg/mL were showed to more abuse these as would cigs smokers or other e-cigs 57. The CQCT 58 suggested that pharmacies would be able to offer such higher levels, this is an unlikely alternative as these stores have stopped selling tobacco or tobacco-related products, in light of their mission from their Society. We could though consider an approach where vaping stores could offer such higher levels only in cases of prior demonstrated failures on lower dosages. Some form of limitation on the highest threshold could be considered.

Many authors have raised issues, as Rodu did 59, on the potential impact of either a prohibition approach or ban of e-cigs, as these would only impair the ability of smokers to quit this addiction. In Québec, a national consensus on restricting access to smoking products to teens, where greater than 90-93% of stores involved in selling such products do adhere to age verification. Rather than consider prohibition, establishing stricter rules and fines should be considered as could be loss of selling permit of tobacco products. In conjunction with educative programs towards teens, some programs targeting parents and teachers through a demonstrated efficacy educative program 60. We do feel that the benefits of such integrated approaches could prove important in both preventing and stopping smoking in the adult population. In doing so, we should make sure that disinformation around e-cigs should stop, as demonizing these is creating a sense of uncertainty in the users. The gateway theory lacks data 61, and temporality has not confirmed causality of e-cigs toward cigs, and it appears that the only common aspect lies in common risk factors. If any gateway would exist, it would only account for 1-7% of teen smoking at best.

We do agree that some gaps on the clinical aspect of e-cigs could be missing, as such aspect of long-term safety should be assessed especially that up to 71% of smokers are using e-cigs as smoking cessation option of choice 62. Such data will be acquired with usage and through time. But we at least know that the elimination of combustion as a vector to nicotine does reduce the known risk associated with cigs 63. Denial of such fact is to condemn smokers to risks that we can eliminate, and such denial represents an ethical debate 64. Some in the public health setting have hailed the e-cigs as the Holy Grail 65 against smoking and tobacco. In the case of HIV, the advent of triple therapy saved lives but subjected patients to side effects that we now have to manage. With this new COVID-19 vaccine and the pandemic, our society has no other choice but to push for a massive general vaccination campaign, despite that long term side effects are yet to be fully assessed. But in light of emergencies, we do need to act. It is the same for e-cigs: as we can save smokers while protecting teens at the same time, without putting that first group at risk, nor the second. While access to flavours should remain, we do agree that cotton candy might be one too many for sure. In such a sense, we believe that the December 9th report from the CQCT 66 expresses biases that are far from the reality, amplifying falsehoods that have been proven wrong and numbers around teens in gateway or usage that are far from the reality. We do believe that the Ministry report 67 showed flaws and should be addressed in open consultation so all elements involved directly or indirectly in this could express perspectives and realities.

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