The Lung Association of Nova Scotia and Smoke-Free Nova Scotia, with funding from Heart and Stroke, released the report “The 2020-2021 Youth and Young Adult Vaping Project.” The study claims that the results of the survey are evidence to support policy changes including a flavour ban, taxation, stronger enforcement of sales regulations, increasing the minimum legal age, and increasing awareness of the potential for vaping to translate into cigarette smoking.

Throughout the CVA’s review, it is apparent that the data has been carefully chosen to support these predetermined policy recommendations. An objective analysis finds the data has been selectively collected to support these preconceived recommendations with no consideration for the macro impact on public health.

While this report aims to address the issue of youth uptake, it uses dated data to substantiate its claim while omitting more recent data showing a decline in youth vaping rates[1]. Dr. David Hammond, whose research is cited to support this claim and has driven Canadian policy on vaping, has himself recently stated, “It looks like we may have reached the peak of youth vaping. I would expect that vaping will continue to decline among young people, and if that happens in parallel with the continued reduction in smoking, then that’s very good news for everybody.”

The Youth and Young Adult Vaping Project continues this pattern of withholding pertinent information, by omitting questions pertaining to flavours within Nova Scotia. At the time of the survey, Nova Scotia had implemented a ban on flavoured products. If the researchers believed that the ban on flavours had been effective in reducing youth use and the results may have skewed the national data, the data should have been collected and reported as two figures – one inclusive of the findings in Nova Scotia and a second excluding Nova Scotia with an explanation as to why. It is curious that the report chose not to collect this data and that no study has been conducted on youth vaping in Nova Scotia since the flavour ban. Given the study conducted by the American Cancer Society[2], which found removing flavours had no impact on youth use, it is likely that this is also true within Nova Scotia. It is the CVA’s belief that the flavour ban in Nova Scotia has been ineffective at preventing youth use and has instead increased traditional smoking rates among adults. However, since this data was not collected there is no way to verify this, which perhaps was the intent of the omission.

The report also fails to benchmark against adult surveys. Adults were not the focus of the survey, but without any context as to how the youth data compares to the adult population, it misleads its audience to believe youth prefer flavours to a greater extent than adults. Market research and industry sales data indicate that flavour use is comparable among youth and adults. About 90% of adults use a flavoured product. If flavours were banned, a percentage of youth may stop vaping, but the same is true for adults. In both cases traditional smoking rates increase.

Moreover, while the study does disclose the ages of the participants, the focus on youth uptake is misleading as the mean age of participants was 18.63 years. This is important to consider as 18 is the age of majority across several Canadian provinces. This demonstrates that nearly half the data within the survey is from legal adults.

To support its flavour ban policy recommendation, the report states, “Other nations, such as the United Kingdom, have also banned or restricted flavours.” This statement is unequivocally false. The United Kingdom has taken no action to ban or restrict flavoured vape products. Certain additives have been restricted but the UK has implemented no restrictions on flavours. It is interesting that the report uses the UK as an example of restrictive policy, considering the UK has embraced vaping as a harm reduction tool. Public Health England and King’s College London are global leaders in vaping research. The UK is so confident in vaping’s relative risk and efficacy that the country has run many campaigns encouraging smokers to switch to vaping and have even opened vape stores within the country’s hospitals[3].

Policy Recommendations

Flavour Ban

The report cites the following data as conclusive evidence a flavour ban is needed:

·       Almost all users used a flavoured vape juice at initiation (91.9%) and presently (90.3%).

·       In most provinces, berry, mango, and mint/menthol were the most reported flavours used at initiation and at present.

Considering flavoured vape products account for about 90% of the products available in the marketplace[4], it is unsurprising that youth are using products consistent with product availability. The CVA also does not refute that youth likely prefer flavoured vapes. People of all ages prefer flavoured over unflavoured for all product categories. The report fails to prove that flavours are the primary reason for youth use and their removal would protect youth without harming the rest of the population.

The survey found that the strongest influence to start vaping for the whole sample were peers, followed by the desire to quit smoking and social media exposure. Within the survey’s own findings, flavours are not listed as an influence. Interestingly, the second greatest influence to start vaping was to use the product as intended – to quit smoking. The survey finds that the majority of users surveyed were former tobacco users (64%). This indicates that, while measures to protect youth may be warranted, vaping has reduced harm and, in most cases, transitioned combustible tobacco use to a less harmful nicotine delivery system[5]. Vaping is clearly a gateway away from combustible tobacco. Despite the studies conclusion that vaping acts as a gateway to smoking, smoking rates among all age demographics continue to decline[6].

Many other surveys argue against flavours being the primary reason for youth uptake. Most notably, “Tobacco Product Use and Associated Factors Among Middle and Highschool Students,” conducted by the CDC found that 77.7% of youth vaped for reasons other than flavours. The most common reason for use was curiosity. More recently the McCreary Youth Centre, released a report which surveyed youth in British Columbia at 3 intervals throughout the pandemic, and found that mental health issues such as anxiety and feeling sad had emerged as strong influences to vape. These surveys signal a need for better preventative education for youth and increased mental health supports to prevent youth uptake.

Furthermore, there is growing evidence to support flavours as a key component in vaping’s efficacy for adult smokers[7]. Yale researchers found that adults that quit smoking using a flavoured product 2.5 times more likely to be successful quitting smoking. The study concluded, “While proposed flavour bans are well-intentioned, they have disastrous outcomes. Legislation on vaping flavours must take the facts of smoking cessation and harm reduction into account, and we urge legislators against the widespread implementation of such bans.”

Taxation

The report states the following:

·       “Taxation and further regulatory measures aimed at specialty vape shops are needed to both deter youth and reduce the likelihood of them acquiring vaping products through this outlet.”

·       We expect the pricing of vape products to be consistent with cigarettes

There is conclusive evidence that vaping is significantly less harmful than combustible tobacco[8]. Excise taxes are intended to prevent harm and compensate for the damage to society as a result of the harmful nature of the product. Vaping prevents harm to society by transitioning smokers to a less harmful product. Widespread adoption of vaping by smokers will alleviate the direct costs to our health care system and prevent premature death and illness caused by tobacco.

Excise taxes are regressive by nature and disproportionately burden individuals in lower socioeconomic positions and those with a mental or physical dependence. Smoking prevalence is greater with many minority groups including individuals with poor mental health, First Nations and Indigenous communities, homeless individuals, and individuals who identify as LGBTQ+. The reports recommendation fails to consider equity in policy and the relative risk of the product.

In a recent tax commentary[9], Dr. Ian Irvine states, “…this Commentary recognizes that cigarettes kill and that if alternative nicotine systems are known with certainty to contain a small fraction of the toxins in cigarettes, this is sufficient to attempt to divert users away from the killer products toward the lower-risk ones, even with uncertainty surrounding the lifecycle health impacts of the latter.”

The reports discussion correctly states that several American states and global jurisdictions have previously implemented taxation as a measure to discourage youth use. However, it fails to provide context on the outcome of this policy. Many studies have found that increased vapour product taxes have resulted in increased smoking rates and slowed vaping adoption rates.

Minnesota conducted a study[10], that found taxing vaping products lead to an 8.1% increase in tobacco use and a smoking cessation decrease of 1.4%. It also found that if vapour products had not been taxed an additional 32,400 adults would have quit smoking.

Minnesota’s findings are further supported by the National Bureau of Economic Research[11] which found that “while cigarette taxes reduce cigarette use and e-cigarette taxes reduce e-cigarette use, they also have important interactions on each other… E-cigarettes and cigarettes are economic substitutes. So, if you raise taxes on one product, you will increase use of the other.”

Pesko and other researchers drew upon sales data from 35,000 retailers across the United States for a seven-year period and concluded that for every 10 percent increase in e-cigarette prices, sales of the vaping product dropped 26 percent. The higher tax on e-cigarettes resulted in an 11 percent increase in sales of traditional cigarettes.

“We estimate that for every one e-cigarette pod no longer purchased as a result of an e-cigarette tax, 6.2 extra packs of cigarettes are purchased instead,” Pekso said. “The public health impact of e-cigarette taxes in this case is likely negative.”

With the recommendation of a substantial excise tax, the report again fails to consider the consequences to all. The report’s sole focus on youth use has led to recommendations that will harm adult smokers and their families. Vape product taxation must be proportional to the harm of the product, or the willingness of smokers to transition to a less risky product will be more limited.

Increase the legal age to purchase vape products to 21

This is perhaps the most bizarre recommendation of the 5. Increasing the minimum age of a harm reduction product without increasing the minimum age of tobacco, a product widely known to kill half of its users, will undoubtably transition some youth to a now more accessible and harmful product.

Canada experienced a record 17% reduction in youth smoking rates at the peak of vaping’s popularity. The Canadian Student Tobacco and Drugs Survey (CSTADS, Government of Canada) details steep increases in vaping among Canadian students and an accompanying decline in cigarette use for the 2017-2019 period[12]. Dr. Hammond also reports a substantial decline in youth vaping during 2020 in the US, Canada and England.

“Policymakers must recognize the scale of the decline in youth smoking. It is ‘historic’, and remarkable, given that the declines came at a point when youth-smoking prevalence was already low. The OSDUS illustrates that, beyond the dramatic and opposing movements in vaping and smoking rates, youth are increasingly conscious of safe behaviour. In addition to switching to a less toxic form of nicotine, major declines in alcohol abuse and drunkenness and other hazardous behaviours are also in evidence[13],” said Dr. Irvine.

Youth should not vape, but for youth that are more susceptible to risk taking behaviours, vaping is demonstrably less harmful. Of course, actions should be taken to protect youth from nicotine dependence, but policy must be carefully considered to ensure that the unintended consequence does not increase the likelihood of more risky behaviours.

Increasing awareness of the potential for vaping to translate to cigarette smoking

There is no evidence to support the gateway theory. Smoking rates among all demographics continue to decline[14]. Youth and young adult smoking rates are at historic lows. The survey itself finds that on average for the demographics surveyed, 64-75% of vape product users are former tobacco users and 11.8% are current tobacco users. It is possible that a small percentage of users may transition from vaping to smoking. However, the data indicates a higher likelihood for these individuals to engage in risk taking behaviour.

Stronger enforcement of sales regulations

The CVA agrees that stronger and more consistent enforcement of sales regulations is needed. Bad actors are a minority and exist within any industry. The CVA has repeatedly advocated for the government to implement strong reporting channels and to consistently enforce the existing laws. Without a legitimate reporting mechanism, there is no pathway for the industry to eliminate bad actors.

However, the report specifically targets specialty vape stores several times throughout the discussion of its findings. There is no data to suggest that vape retailers are selling to minors at a rate exceeding that of convenience outlets. Most sales to minors (60-72%) are happening through straw sales[15]. Harsher penalties for selling to minors and greater enforcement is needed to combat this.

As stated in the survey, convenience stores were the primary access point for youth in Ontario. Ontario was the first province to limit the sale of flavoured products to age restricted specialty vape stores. This survey is an indication that this type of policy is effective. However, it should be noted that the survey discussion states that it is unclear whether youth are purchasing products through convenience or vape store channels themselves or if products are being purchased by an adult.

It should also be noted that as convenience store access points increased, so did youth vaping rates. Limiting access points in combination with consistent enforcement is the key to curbing youth vaping rates. Convenience outlets are not equipped to provide product recommendations (choosing a device type and matching nicotine content to a smoker’s daily nicotine intake), or to provide guidance to smokers throughout their transition to vaping. Vape products require a specialized knowledge of the various product offerings and an understanding of the transition process that non‐specialty stores are ill‐equipped to provide. High nicotine and flavoured products should only be available in age‐restricted specialty stores.

Conclusion

The CVA acknowledges that the concern surrounding youth vaping is legitimate. Youth and non-smokers should not vape and should be discouraged and educated on the risks. However, the lives of smokers must remain the primary concern. Policy recommendations that fail to recognize the substantial difference in harm between nicotine vaping and combustible tobacco, will ultimately cause significant harm to public health. Adult smokers and vapers have a constitutional right to access effective harm reduction products. Policy recommendations must take the rights of Canadians into account.

Further, the credibility of the recommendations must be called into question when the data is misrepresented and opposing findings are completely omitted from the report. The vape industry has invited the government and health organizations to work together to find an effective solution to combat the problem, but the offer has never been pursued.

Recently, Clifford E. Douglas, former Vice President of Tobacco Control for the American Cancer Society and founder of the Center for Tobacco Control released an open letter calling for the ‘end of the internecine warfare over e-cigarettes’[16]. “I urge all of us in the tobacco control community to climb out of the bunker, come to the table, and try to genuinely work together. Stop skirting the truth when it feels inconvenient and open your minds and ears to all of the science that is before us. But the same goes for my other community, with whom I agree regarding the evidence-based promise of THR, but which also bears some responsibility for the adversarial nature of the relationship and for not consistently acknowledging areas of ambiguity or concern, including significant rates of experimentation with vaping by youth and youth-oriented marketing by some segments of the vaping industry. We won’t come together if we don’t come together.”

Douglas also refers to Dr. Steven Schroeder’s presentation[17] at The E-Cigarette Summit (2020), where he stated, “this pandemic is one of lost integrity, internal warfare, and ideological polarization between those who seek to marginalize or even eradicate e-cigarettes and those who advocate their use for harm reduction in adult smokers. This pandemic misrepresents scientific findings, and misleads the public, the media, and health professionals about the science.”

The 2020-2021 Youth and Young Adult Vaping Project is the culmination of years of misrepresented science. The vape industry acknowledges that action is needed to protect youth, yet anti-vape proponents refuse to acknowledge vaping’s efficacy and harm reduction potential. If implemented, the policy recommendations within the report will lead to thousands of premature deaths from smoking. Frankly put, these recommendations will kill people.

The common ground called for by Douglas can not exist until Canada’s health organizations propose policy that is routed in science and in the interest of all citizens.