Health Canada recently sought comments on proposed regulations to ban most flavouring ingredients in vaping liquids, with the exception of a limited number of ingredients to impart tobacco or mint/menthol flavour.

This proposal is based on four assumptions:

• There is apparently a “vaping epidemic” among young Canadians.
• Flavoured liquids are believed to be one of the main factors contributing to the rapid increase in vaping among young people.
• Vapers will develop a nicotine addiction and start smoking cigarettes. In other words, vaping would be a stepping stone to tobacco, what is colloquially called the “gateway effect”.
• As a result, eliminating flavours from vaping liquids will discourage e-cigarette use and thus help prevent youth smoking.

The goal of protecting young people from tobacco is obviously laudable, but a careful examination of the data accumulated over the past few years raises several doubts about the effectiveness of banning flavoured vaping liquids to achieve this. In addition, this project completely ignores the potentially devastating effect of such a ban on adults who use flavoured electronic cigarettes to quit smoking. Before eliminating vaping flavours from the current market, we believe it is important to take a step back and examine the potential negative impacts of this ban, both among young people and adult smokers.

Youth smoking is at an all-time low. First of all, it is important to mention that we have made spectacular progress in the fight against youth smoking. Surprisingly, very little is said about it, but the number of high school students who smoke cigarettes regularly is currently at an all-time low, with only 3% of young smokers aged 15–19 in 2020 in Canada, compared to more than 30% in the late 1990s. A similar phenomenon is observed in most industrialized countries: in New York, for example, there are only 2.4% of smokers in high school compared to 27% in 2000. In concrete terms, this means that over the last 20 years, we have reduced the proportion of young smokers by 90%, which is phenomenal.

Of course, we may wish to reduce this number even further, but we must nevertheless admit that the efforts of recent years in the fight against tobacco have borne fruit and that we have collectively succeeded in making smoking a marginal and old-fashioned behaviour, rejected by the vast majority of young people. Given that more than 90% of adult smokers started smoking as teenagers, this means that the next generation of adults will be overwhelmingly non-smokers and consequently much less affected by the health problems caused by smoking (especially lung cancer) than previous generations. The current status quo therefore represents an unprecedented victory in the fight against tobacco.

Few young people vape regularly and those who do are smokers or ex-smokers. The number of young people who vape has actually increased in recent years. The latest statistics show that in 2019, around 41% of 16–19 year-olds had tried these products at least once, compared to 29% in 2017. On the other hand, it should absolutely be mentioned that this number of vapers is artificially inflated by including young people who have only experimented with electronic cigarettes on a few occasions. When we restrict the analysis to those who use e-cigarettes at least 20 times per month, the data is much less spectacular, with 5.7% regular vapers (see our article on this). In addition, the vast majority of these regular vapers are smokers or ex-smokers, with barely 1% who have never smoked cigarettes. Strictly speaking, there is therefore no vaping epidemic, especially since the latest US data indicates that the proportion of young vapers has decreased by 50% in the last two years, which could indicate that vaping is much more of a passing fad than a lasting transformation in the habits of young people.

Could this vaping among young people, even if it does not reach truly epidemic proportions, still erase this progress and lead to an upsurge in youth smoking? Tobacco control organizations seem to think so and that is why they want to eliminate flavours from vaping liquids to make e-cigarettes less appealing to young people. In other words, it is a question here of making electronic cigarettes “ugly” to reduce their attractiveness and social acceptability and thus prevent exposure to a nicotine-based product from causing young people to turn to tobacco (gateway effect).

This fear of a stepping stone to tobacco is in a way similar to the old mentality of the war on drugs. At the time (towards the end of the 1960s), it was believed that drug users were irremediably attracted by increasingly dangerous products. According to this belief, a cannabis smoker was at a very high risk of becoming a heroin addict, as if people who were attracted to one drug were unable to control themselves and were doomed to always want to go further, even if it meant destroying themselves. We now know that these fears were completely unwarranted and that just because people enjoy the effects of a recreational drug does not mean that they will become irrational. The legalization of cannabis reflects this change in perception of soft drugs.

The same reasoning can be applied to vaping: why would a young person who likes vaping decide to “go further” and turn to a source of nicotine known to be harmful, less appetizing, more expensive, and completely rejected by society like cigarettes? The data accumulated in recent years indicate that this is indeed unlikely and that far from being a stepping stone to tobacco, electronic cigarettes could instead represent a substitute for traditional cigarettes.

Vaping does not lead to smoking. First of all, it should be pointed out that the hypothesis of the gateway effect is completely incompatible with the current situation of youth smoking. Even though electronic cigarettes have been available for several years, the reality is that the proportion of young people who smoke tobacco cigarettes continues to decrease year after year. The arrival of the “pod mod” type electronic cigarettes (Juul, for example), which are even more efficient in terms of nicotine absorption, did not affect this downward trend in smoking among young people and, on the contrary, even accelerated it. In other words, the “vaping epidemic” among young people, so much decried by anti-tobacco organizations, has not led to an increase, but rather a marked decrease in youth smoking, something that would obviously be impossible if vaping led young people to smoke cigarettes.

The claim that vaping is a gateway to tobacco is based on a misinterpretation of studies that have addressed this issue. These studies show that electronic cigarette use is indeed associated with an increased risk of cigarette smoking, which may seemingly validate the existence of a gateway effect. In reality, however, it is impossible to establish a direct cause and effect link between the two behaviours due to what is called “common liabilities”: young people attracted by nicotine will experiment with several forms available, without this meaning that trying one will push them toward another.

In practice, studies show unequivocally that the vast majority of vapers are smokers or ex-smokers, with less than 1% of regular vapers who have never smoked. This suggests that if there is a gateway effect, it is rather in the opposite direction (and positive in terms of reducing tobacco damage), i.e. from cigarettes to vaping.

Vaping is a substitute for smoking. Like it or not, nicotine has long been a recreational drug that attracts significant numbers of young people. For a long time, tobacco was the only available source of this drug, and it is for this reason that rates of youth smoking reached worrying highs until the early 2000s. However, this is no longer the case today, at least in industrialized countries. The electronic cigarette now competes directly with tobacco and represents in practice a much more attractive alternative for nicotine users.

In addition to a better taste (because of the flavours added to vaping liquids) and being devoid of the defects of smoked tobacco (the smell, in particular), a marked advantage of the electronic cigarette is that it is a lot less harmful to health than traditional cigarettes. While the combustion of tobacco generates several thousand highly toxic and carcinogenic compounds that dramatically increase the risk of developing a host of pathologies, in particular cardiovascular disease and lung cancer, the amount of most of these compounds is reduced by 99% in the vapour emanating from electronic cigarette devices (see our article on this subject). According to several major scholarly associations (Public Health England, Académie française de médecine, National Academies of Science, Engineering and Medicine of the United States), electronic cigarettes are at least 20 times less harmful than smoked tobacco.

Vaping therefore has several competitive advantages over smoked tobacco, and it is for this reason that this new technology is establishing itself as a substitute for tobacco cigarettes among nicotine users. Economic analyses also confirm this role of substitution, since an increase in the tax on one of the products (tobacco or electronic cigarettes) leads to a decrease in the consumption of the taxed product for the benefit of the other. For example, one study showed that an increase in the tax on electronic cigarettes was associated with a reduction in vaping and a parallel increase in the sale of tobacco cigarettes. Conversely, an equivalent increase in the tobacco tax leads to an increase in the number of vapers. The two products are therefore substitutes from an economic point of view, which is why a decrease in the competitiveness of the electronic cigarette due to a higher price results in an increase in smoking. It has been estimated that for each cartridge (pod) of vaping liquid that is not purchased due to a tax increase, an additional 6 packs of tobacco cigarettes will be sold. Since a ban on flavoured vaping liquids will also decrease the competitiveness of e-cigarettes, there is concern that a similar phenomenon could occur (see next sections).

Overall, these observations suggest that the electronic cigarette can in a way be considered as a disruptive technology, i.e. an innovation that has the potential to compete with tobacco and even possibly replace it as the main source of nicotine consumed by the population (e.g. digital cameras that have eliminated film cameras).

This is very interesting, since there is usually no going back when one technology supplants another. To take a simple example, streaming has made DVD movie rental clubs a thing of the past, just as DVDs had previously driven VHS tapes out of the market. It is unthinkable that we will ever go back to these old technologies, just as we can be sure that the dial telephone will never take the place of our current cellphones. The electronic cigarette therefore has the potential to eliminate tobacco cigarettes in the medium and long term, a product which, it should be remembered, is responsible for nearly 8 million premature deaths each year. The multinational tobacco companies are perfectly aware of this evolution of the market and it is for this reason that they are gradually turning away from traditional cigarettes to develop less harmful electronic versions, and even anticipate the outright disappearance of traditional cigarettes in the next 10 to 15 years.

Banning flavours could lead to an increase in youth smoking. The main fear invoked to justify the ban on flavoured vaping liquids, namely a massive migration of young vapers to traditional cigarettes, therefore seems unjustified and one can wonder about the relevance of changing the current status quo. Especially since it is necessary to consider that the ban on flavours could have effects contrary to those sought. Since it appears increasingly obvious that the electronic cigarette is a substitute for tobacco cigarettes, isn’t there a risk that by discouraging vaping we push young vapers who are more addicted to nicotine toward tobacco? As Public Health England recently put it, “If an approach makes e-cigarettes less accessible, less palatable or acceptable, more expensive, less consumer-friendly, or less pharmacologically effective, then it causes harm by perpetuating smoking.”

Given that the strategy of banning vaping flavours is fairly recent, it is not yet clear exactly how young people will react to the disappearance of these flavours. On the other hand, the preliminary data are very worrying; a study carried out in the San Francisco area, where a ban on the sale of flavoured vaping liquids has been in effect since 2018, recently showed a significant increase in the number of young people who smoked cigarettes after the introduction of this measure, while the smoking trend continues to decline in other parts of the United States where these flavours have not been prohibited (Figure 1).

Figure 1. Impact of a law banning vaping flavours on youth smoking. From Friedman (2021). Note the increase in the number of teenagers who smoked cigarettes following the implementation of the law banning flavours in 2018 (arrow).

A survey of young adults aged 18–34 paints a similar picture: When asked what they would do if vaping flavours were banned, 33.2% responded that they would likely use tobacco cigarettes as a source of nicotine. Therefore, there seems to be a significant proportion of young vapers who could make the jump to tobacco cigarettes in response to the disappearance of vaping flavours, which is obviously the reverse of the desired effect. In our view, if the objective of the project to completely ban flavoured vaping liquids is to prevent an upsurge in youth smoking, these observations should at least cause a delay in the application of this measure while waiting to be able to confirm or not this upward trend. In a sector where two products are in direct competition with each other, any attempt to make one of the two products less attractive (by taxing it or banning flavours, for example) is likely to strongly favour the other. Given the catastrophic health effects of tobacco, this is a huge risk that deserves careful consideration.

Vaping flavours play an important role in smoking cessation. Adult smokers are largely forgotten in the current debate on electronic cigarettes, even though they are by far the main users of these products. There is a lot of talk about the (very hypothetical) dangers of an upsurge in youth smoking caused by vaping, but the huge, clinically proven contribution of e-cigarettes as a smoking cessation aid is completely overlooked. In randomized clinical trials (the standard of excellence for clinical research), it is observed that electronic cigarettes are about twice as effective in leading to smoking cessation than traditional approaches (patches, gum). This is particularly true for heavy smokers, who are very dependent, where an even more impressive success rate is observed for electronic cigarettes, 6 times higher than with standard nicotine substitutes.

There is nothing abstract or theoretical about the effectiveness of electronic cigarettes in promoting smoking cessation: surveys reveal that at least 4.3 million Americans, 2.4 million Britons, and 7.5 million Europeans have quit smoking thanks to these devices, at the same time drastically reducing their risk of dying prematurely. There is therefore no doubt that electronic cigarettes have strongly contributed to the significant decline in adult smoking worldwide, from 23.5% in 2007 to 19% today.

The argument often invoked by opponents of vaping, namely that it is not proven that the electronic cigarette can help with smoking cessation, therefore does not correspond at all to the scientific reality and to that experienced by many ex-smokers for whom this new technology has literally saved their lives.

Flavoured vaping liquids are extremely important in enabling smokers to adopt e-cigarettes. Surveys on this subject show that adults much prefer fruit, dessert and candy flavours to that of tobacco. Flavours are therefore not only appealing to young people, because for a smoker looking to break their addiction to cigarettes, tobacco flavoured vaping liquids are often the last thing sought. Banning flavoured vaping liquids would therefore have the direct consequence of eliminating the main appeal of electronic cigarettes, consequently reducing the number of smokers who could adopt this method to break their addiction to cigarettes. In our opinion, this is a huge collateral damage to the proposed flavour prohibition, since the acceptability of a substitute for cigarettes is essential for quitting. In fact, a recent study showed that adult smokers who started vaping flavoured liquids (fruit, candy, chocolate, etc.) were more likely to be able to quit smoking than those who used tobacco flavours.

For all of these reasons, it seems to us that banning vaping flavours is a very bad idea. The effectiveness of this measure in stopping vaping among young people is questionable (flavours are only one of the factors that encourage vaping), and it is certain that it will have negative impacts on adult smokers by eliminating an alternative to tobacco. It should also be mentioned that a decrease in the number of adults who quit smoking has a negative impact on young people, not only because parental smoking is the main risk factor linked to the initiation of smoking in children and adolescents, but also because of the psychological trauma caused by the disease and/or death attributable to smoking in adults around them.

The disagreements over the issue of vaping reflect the evolution of two major schools of thought in the fight against tobacco. On the one hand, there is what we might call “abstentionists” or prohibitionists, for whom the only way to reduce smoking is to abstain completely from any product that contains nicotine, even when it is well documented that these products are much less harmful than smoked tobacco. Seeking to reduce the number of vapers by banning flavours, despite the fact that these products are much less dangerous than tobacco, is a good example of this “all or nothing” approach. In practice, we are no longer talking here only of the fight against tobacco, but rather of a more general fight against nicotine as a recreational drug, even if this drug has no major effects on health as such.

On the other hand, we find the “pragmatists” who are much more interested in concrete results (reduction in tobacco-related illnesses and mortality) than in the means to achieve them. In this approach, cigarettes remain the enemy to be defeated and anything that can reduce the damage caused by the combustion of tobacco is valued, especially when the experimental data clearly show a decrease in toxicity, as is the case for electronic cigarettes. The British are the leaders in this harm reduction approach and the public health agency of this country (Public Health England) strongly encourages all smokers to migrate to electronic cigarettes.

I firmly believe that this pragmatic approach to reducing the harm caused by tobacco is the best. Abstinence is a good virtue in theory, but the reality is that many smokers are extremely addicted to cigarettes and are absolutely unable to quit without a substitute allowing them to absorb an amount of nicotine equivalent to that found in tobacco. I can no longer count the number of my patients who had tried everything, without success, to overcome their addiction to tobacco, until the day they tried e-cigarettes and finally succeeded. A success that has been in many cases a true question of life and death, because there is no doubt that many of them would have died by now if they had not succeeded in quitting smoking. It would be extremely unfortunate if individuals who have to deal with a very heavy tobacco addiction were deprived of the best tool identified so far to quit smoking, namely vaping of flavours other than tobacco.

OVERVIEW

• 218 healthy and non-obese people were separated into two distinct groups: one control group where people could eat without restrictions and another whose goal was to reduce their caloric intake.
• For two years, the researchers measured variations in several cardiovascular risk factors, including body weight, cholesterol levels, blood pressure and insulin production.
• The results show that a reduction of only 12% in caloric intake (or 300 calories per day) is associated with a significant improvement in all of these risk factors and could therefore represent a simple way to reduce the risk of cardiovascular diseases.

A recent report found that in 2016, 60% of the population of Organisation for Economic Co-operation and Development (OECD) countries were overweight, including 25% who were obese. This is huge, and this trend will likely worsen in the coming years due to the dramatic increase in the incidence of overweight among young people: in Canada, for example, the obesity rate among children aged 5 to 19 increased from 2.7% to 12.3% between 1975 and 2016, plus another 20% of children who are considered “pre-obese” and therefore at high risk of obesity. These statistics are alarming because being overweight, and particularly obese, significantly increases the risk of type 2 diabetes, cardiovascular and respiratory diseases, and several types of cancer. According to the OECD, the current situation is likely to reduce Canadian life expectancy by 3 years by 2050 (confirming the pessimistic scenario envisaged a few years ago by some researchers), with catastrophic economic and social repercussions.  

Excess calories
Contrary to popular belief, the high incidence of overweight in the population is not due to lack of exercise. This discourse comes from multinational food companies that seek to promote their high-sugar and high-fat products by suggesting that it is enough to adopt an active lifestyle to counterbalance the caloric intake provided by these products. In fact, studies indicate that it is practically impossible to “burn” the enormous amounts of calories from these processed industrial products and that one therefore cannot compensate for a poor diet simply by being physically active (“you cannot outrun a bad diet,” as the saying goes). In fact, physical activity levels have remained virtually unchanged in the last thirty years in industrialized countries, so a sedentary lifestyle alone cannot explain the phenomenal increase in population waist circumference that has occurred in recent years. Rather, it is the overconsumption of calories, especially those from ultra-processed industrial food, that is largely responsible for the current worldwide obesity epidemic. To avoid gaining extra pounds, the most important thing is to eat less.

Caloric restriction
Several studies suggest that a reduction in caloric intake is associated with several health benefits, especially at the cardiovascular level, as well as an increase in life expectancy. For example, a study of primates (rhesus macaques) showed that a low-calorie diet reduced the incidence of cardiovascular disease in these animals by about half compared to a standard diet. A similar phenomenon has been observed in humans, i.e. people who drastically reduce their caloric intake to about 1200–1900 kcal/day over a 6-year period showed a dramatic improvement in several cardiovascular risk factors (cholesterol, blood pressure, fasting glucose and insulin, inflammation) compared to those who consumed a standard North American diet (2000–3500 kcal/day).

However, this type of severe caloric restriction is very difficult to maintain over long periods of time for most people, and therefore is not really applicable at the population level. In contrast, a recent study suggests that significant improvements in cardiovascular health can also be seen following a much more modest reduction in caloric intake. In this phase 2 clinical study called CALERIE (Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy), the researchers randomly separated 218 healthy and non-obese people aged 21 to 50 (BMI between 22 and 28) into two distinct control groups: in one control group, people could eat without any restrictions (ad libitum), and in the other, the objective was to reduce caloric intake by 25%. Over a two-year period, several cardiovascular risk factors were measured in both groups, including blood pressure, cholesterol levels, C-reactive protein (a marker of inflammation), insulin and metabolic syndrome (estimated by combining waist circumference, blood pressure, fasting glucose levels, and triglycerides and HDL cholesterol levels).

Participants’ follow-up shows that the objective of reducing the caloric intake by 25% in the experimental group could not be achieved, with a reduction half as small (12%), which corresponds on average to 279 fewer calories/day at the end of the first year and 216 fewer calories/day after two years. Nevertheless, although relatively modest, this reduction is associated with an average weight loss of 7.5 kg (or 10% of the initial weight) and a significant improvement in all cardiovascular parameters measured in the study (Figure 1). Conversely, the volunteers of the control group gained on average a little weight (0.1 kg) and showed no improvement in these various parameters.

Figure 1. Improvement of several cardiovascular risk factors due to a reduction in caloric intake. From Kraus et al. (2019).

In sum, these results indicate that even in thin and healthy people, a modest reduction in caloric intake (about 300 calories per day, which corresponds to only a slice of pizza) has several positive effects on cardiovascular health. According to the authors, it is likely that these benefits will be even more pronounced in people who are at higher risk of cardiovascular disease due to being overweight. The preventive potential of caloric restriction is therefore immense: according to the OECD report cited earlier, if people in the richest countries, including Canada, reduced their caloric intake by 20%, we could prevent annually 1.1 million cases of cardiovascular disease and save up to $13 billion (USD) each year, a goal that is absolutely impossible to achieve with medication alone.