Monday 31 May 2021

Nunavut leads the way (again)

 Last Fruday the Nunavut Legislative Assembly ture gave its approval to Bill 57, the "Tobacco and Smoking Act." By pioneering measures that address emerging tobacco control concerns, this new law provides a model for other Canadian governments.

Hon. Lorne Kusugak
Nunavut has even more reason than other provinces to give priority to tobacco. As the Minister of Health, Lorne Kusugak, reminded his colleagues, smoking rates in Nunavut are 4 times those in southern Canada. He estimated that three-quarters (74%) of Nunavut's citizens smoked, and that even among teenagers, rates were more than 50%. 

The Minister explained that the measures in Bill 57 covered four broad themes: protection from second hand smoke, preventing young people from using tobacco, denormalizing tobacco use and regulating emerging products like vaping devices. Before being reviewed in committee-of-the-whole, the bill had been considered and approved by the Standing Committee on Legislation.

The Legislative Assembly not only supported Minister Kusugak's proposal, they strengthened it during their final review. Provisions that would have grandfathered the right to smoke in publicly funded rental housing were removed in order to accelerate the protection from smoke for other residents. 

Bill 57 did not amend the previous tobacco law, but replaced it. The Minister noted that "aside from some consequential amendments introduced in 2018, Nunavut’s tobacco control legislation has not been amended in 15 years and updates are needed for this legislation to be effective."

With a few exceptions, Nunavut's tobacco control legislation is the strongest in Canada. Key advances include:

  • raising the minimum age for sale from 18 to 19 (only PEI has adopted the higher minimum age of 21)
  • banning all flavours in vaping products (other than tobacco) (Nova Scotia and Prince Edward Island are the only other jurisdictions to have done this). 
  • banning internet sale of vaping products (Quebec is the only other jurisdiction to have done this)
  • banning manufacturers or wholesalers from offering incentives to retailers (Quebec is the only other jurisdiction to have done this), and banning retailers from offering any incentives to customer

Nunavut also moved forward with regulatory innovations, becoming a Canadian leader by adopting measures which:

  • ban flavourings designed to be added to flavourless vaping porducts
  • ban the display of tobacco or vaping product prices (although a price list may be available). 
  • ban the sale at different prices to retailers or customers in the same municipality  
  • ban smoking in publicly funded housing 
A comparison of Nunavut's controls on vaping products with those in place elsewhere in Canada is available here. 

This is not the first time that Nunavut has led the way. In November 2003, Nunavut's legislature became the first in Canada to adopt a law to ban smoking in all workplaces, including bars. Within a few years, the rest of Canada had also done so.

Monday 24 May 2021

Conflicting tobacco control advice in post-Brexit Europe

Last week European public health experts made public their advice to governments on how to strengthen tobacco control in their jurisdictions. These reports were all prepared by knowledgeable and experienced experts and were based on the same body of evidence. Nonetheless, they came to very different conclusions and pointed governments in very different directions. Increasingly, the English Channel has become the dividing line between scientists who are e-cigarette enthusiasts and those who are not.

This post reports on the release of these reports and the significance this could have for Canadian policy-makers.

Report from the European Commission (May 20, 2021)

The 27 Member States of the European Union have agreed on a common approach to tobacco regulation, with minimum standards applying across the region and options for countries to go further if they desire. The current Tobacco Products Directive was adopted in 2014 and came into effect in 2016. In anticipation of revisions to the law, EU officials were tasked with providing legislators with an analysis of its strengths and weaknesses. 

Last week these officials tabled their Report from the Commission to the European Parliament, the Council, the European Economic Social Committee and the Committee of hte Regions on the application of Directive 2014/40/EU concerning the manufacture, presentation and sale of tobacco and related products. Despite its long title, this is a relatively succinct (18 page) report which addresses each of the major provisions of the directive and reports on successes and challenges over directive's first 5 years. 

The report recommends that EU parliamentarians strengthen the tobacco directive in support of the public health goal of reducing tobacco use by 30% between 2010 and 2025. It calls for strengthened warning and packaging systems and requirements for plain packaging across the Union. It reports that efforts to reduce the addictiveness and attractiveness of tobacco products through regulation has proven to be complex and costly, and suggests that this goal be reconsidered. It recommends greater efforts to address the use and sale of e-cigarettes, other novel tobacco products, herbal cigarettes and cannabis-based products. It encourages parliamentarians to impose regulatory fees on tobacco manufacturers to finance tobacco regulation. 

On e-cigarettes the Commission reaffirms its belief in of a "careful and precautionary approach". It notes that its scientific body (SCHEER) found the evidence basis for potential harms from e-cigarette use (respiratory and cardiovascular systems, increased smoking by young people, etc) was stronger than the evidence basis for potential benefits (helping smokers quit or cut down). If e-cigarettes are to have a role in cessation, the commission recommends that "their regulation should follow the pharmaceutical legislation."

By their read of the evidence, there is not yet a scientific consensus in favour of e-cigarette use.  "Views on the actual health effects of e-cigarettes are divided, ranging from harmful to harm-reducing for the individual, compared to conventional tobacco products for smoking. As scientific consensus has yet to be reached, the precautionary principle prevails and the TPD takes a careful approach in regulating these products." The further precautions they suggest include "tank size or labelling requirements; use of flavours; use of nicotine-free liquids; and advertising provisions."

The Commission also released the extensive review of tobacco-related developments in the EU which it had commissioned from ICF SA and RAND Europe. This Support study to the report on the application of Directive 2014/40/EU  provides case studies and background information on European tobacco control. The final opinion of the EU's SCHEER committee had been made public last month.

Report of the Royal College of Physicians. (May 20, 2021)

As a consequence of Brexit, Great Britain is no longer bound to follow EU directives on tobacco control, and is in the midst of building its post-Brexit tobacco plan. The U.K. government's tobacco control strategy, released last year, plans to "identify where we can sensibly deregulate without harming public health or where EU regulations limit our ability to deal with tobacco."

To contribute to a new made-in-UK approach, the Royal College of Physicians tasked its Tobacco Advisory Group to make recommendations to government. This group is made up of 16 U.K. tobacco control specialists, drawn from government, university and civil society.

Their report -  Smoking and health 2021: A coming of age for tobacco control? - makes recommendations in several policy areas. These include higher taxes, mass media campaigns, more powerful health warnings, controls on tobacco imagery in films and video games, putting retail shelving out of sight, enhanced monitoring and protection from tobacco industry interference. The advisory group also calls for the National Health Service to further expand its cessation services, and to cover all smokers unless they "opt out".

A key underpinning of  the approach of the RCP's experts is the desire to encourage smokers to quit by switching to e-cigarettes. A number of regulatory steps are proposed to do this, including reducing taxes on vaping products (they are currently subject to the value-added tax), relaxing rules on vaping in public places, publicly-funded mass media campaigns to encourage smokers to switch to vaping, and ensuring e-cigarettes are included in all quit smoking programs. They implicitly exempt vaping products in their calls to increase the age of sale to 21 and to remove  'tobacco' imagery in cultural products. They ask that government review restrictions on e-cigarette advertising and limits on the amount of nicotine permitted in vaping liquids and "to assess the extent to which the regulations support switching from smoking." 

Unlike the experts working for the European Union, this expert group does not see a need for precaution with e-cigarettes. They do not view youth vaping in the United Kingdom as problematic ("while e-cigarettes might lead a small number of young people into smoking, for others, they may displace smoking" ). The conclusions of the Cochrane review in support of e-cigarettes being efficacious cessation aids are satisfactory to them. Other systematic reviews commissioned by government which come to different conclusions are ignored to the extent that they are not identified or cited in this RCP report - including those prepared by the EU SCHEER, the U.S. Preventive Health Services Task Force, the U.S. Surgeon General, and those commissioned by the Australian government,  the Irish government, the Spanish government, and the Netherlands government )

In advance of World No Tobacco Day, the Geneva-based World Health Organization encouraged governments to scale-up their efforts to reduce smoking and provided advice on how they could do so.

The WHO agrees with the Royal College of Physicians that much more needs to be done to reduce tobacco use and that taxes and smoking cessation programs have a major role to play. It differs greatly, however, on the role of e-cigarettes in accomplishing this. "Switching from conventional tobacco products to e-cigarettes is not quitting" ...  "e-cigarettes are not proven cessation aids".

The WHO Director General, Dr. Tedros Adhanom Ghebreyesus portrayed e-cigarettes as an evolution of tobacco industry manipulation of scientific and public opinion and a new wave of harm: "We must be guided by science and evidence, not the marketing campaigns of the tobacco industry – the same industry that has engaged in decades of lies and deceit to sell products that have killed hundreds of millions of people”.

Scientific pluralism and evidence-based policy 

With their contradictory advice on key issues and their inconsistent assessment of the scientific evidence, the reports issued from Europe last week do not simplify the work of health leaders in Canada or other countries. 

In the absence of a scientific consensus, a government's choice of scientific advisors will play a major role in the determination of policy. Notably, three of the ten members of Canada's first Scientific Advisory Panel on Vaping also contributed to the Royal College of Physicians report. With the mandate of this first panel expired, Health Canada is currently striking a new Scientific Advisory Panel. 

This week's reports from Europe are a reminder that the advice Health Canada will receive is highly dependent on its choice of experts. 

Monday 17 May 2021

Ian Irvine, the Foundation for a Smoke-Free World and the CD Howe Institute

Over the past months Canadians have heard the views on vaping regulations of Concordia University economist Ian Irvine.

Recently the Globe and Mail's business editor gave space to his opinion that taxes on vaping products should not be so high as to discourage people from using them and that governments should do more to encourage smokers who don't quit to switch to the companies' new forms of nicotine products. [1] 

Mr. Irvine and the CD Howe Institute

Two weeks earlier, the CD Howe Institute had published his longer report on the same theme. [2]

This was not the first or the only time that the CD Howe Institute had promoted Mr. Irvine's views on vaping products. At the end of March, they hosted his letter to the federal health minister, encouraging her not to see youth vaping as a crisis, but rather as a driver of lower youth cigarette smoking. [3]

Last fall, Mr. Irvine was the author of a series of CD Howe posts on vaping policies, providing several reasons why alternative nicotine products should be lightly regulated, attributing a decline in cigarette use to the marketing of vaping products, and recommending against new controls on nicotine levels or flavours. [4] [5] [6] Earlier in the year, he had presented the same views in a CD Howe Institute podcast, [7] and was one of several vaping-friendly presenters at the November 2019 CD Howe policy conference "Vaping and E-cigarette Regulation in Canada". [8] 

At no time did the CD Howe Institute acknowledge that Mr. Irvine was working on a contract funded by the Foundation for a Smoke-Free World (FSFW), the most recent in a history of tobacco industry efforts to align public and regulatory opinion with their business interests. 

Mr. Irvine and the Foundation for a Smoke-Free World.

In July 2019, the Foundation for a Smoke-Free World provided a two-year grant to BOTEC for an undisclosed amount. The task assigned with the grant was to "Investigate the Drivers for Smoking Cessation in Five Countries with ANDS Markets", and the key deliverables were to be "Case studies and consolidated research report submitted to FSFW". [9] 

Mr. Irvine was engaged to prepare the report on Canada, which was integrated into Botec's 5-country study. [10] Botec's report and the 5 individual country studies were published last month on the SSRN portals, including Mr. Irvine's "A Multi-Disciplinary Study of the Drivers of Smoking Cessation in Canada." [11] 

In his report, Mr. Irvine concludes that the only measures that have historically reduced smoking rates in Canada are higher prices and smoke-free policies, and that other regulations (health warning labels, plain packaging, etc) have done little other than contribute indirectly to a long term trend. By contrast, opening the market for alternative nicotine products was a "major disruption" to the cigarette market, responsible for cigarette sales declining "precipitously" after 2018. In addition to low taxes, he encourages the federal government to encourage smokers to switch to new tobacco products and criticizes the federal tobacco strategy as beng "directed to tobacco use reduction rather than damage reduction".

The posting of the reports by Botec and Mr. Irvine on the SSRN network in April 2021 was the first public acknowledgement that Mr. Irvine was a third-hand recipient of tobacco industry money: "This work was funded by a grant from the Foundation for a Smoke Free World, which had no control over the work process or the report."

The CD Howe Institute and Conflict of Interest

In the preface to its policy papers, the CD Howe Institute includes a message from its vice president of research. "The Institute requires that its authors disclose any actual or potential conflicts of interest of which they are aware." This text also appeared on Ian Irvine's commentary on vaping taxes. 

From this we can perhaps conclude that the receipt of money from a tobacco-industry funded granting organization was not considered a conflict of interest by the CD Howe Institute management, or not one worth sharing with its policy audience. 

With a former tobacco industry CEO as vice-chair of its board of directors, the CD Howe Institute may not consider that tobacco industry interests are in conflict with its own. (Mr. Brian Levitt headed IMASCO/Imperial Tobacco until it was fully absorbed by British American Tobacco in 2000). 

Undisclosed funding by commercial interests is a public health problem. 

Mr. Irvine is one in a long line of Canadian researchers who have engaged in public discussions on tobacco use and other health-harming products while not disclosing that they have been funded by the industry whose position they are supporting. 

It was decades after the famed psychiatrist Hans Selye discouraged parliamentarians from curbing tobacco marketing because cigarettes helped prevent stress-related disease, for example, that his relationship with the industry came to light. McGill epidemiologist Corbett McDonald failed to disclose that his research into the health effects of asbestos mining was funded by the industry that benefitted from his conclusions that low levels of exposure were safe. In the late 1980s, Philip Morris secretly funded a symposium at McGill University and subsequent publications to allay concerns that smoke-filled offices were a source of illness. Theodore and Elia Sterling at Simon Fraser University were funded to oppose bans on workplace smoking.   

The Foundation for a Smoke-Free world is the modern evolution of an historic industry practice to engage friendly scientists to run interference against regulatory controls. The big funding bodies in the USA were the Tobacco Industry Research Council/Council for Tobacco Research and the Center for Indoor Air Research, famously discredited as a result of U.S. lawsuits. The same  tactics were used in Canada, with the companies working together to support researchers looking at the benefits of smoking, alternative causes of cancer and heart disease, and ways to reduce concerns about second hand smoke.  

The Framework Convention on Tobacco Control

In ratifying the global tobacco treaty and adopting the guidelines on its implementation, the government of Canada has officically adopted the position that the interests of the tobacco industry "are in direct conflict with the goals of public health" and has accepted responsibility to "protect these policies from commercial and other vested interests of the tobacco industry". 

Health Canada has not yet provided guidance to other levels of government, to the media or other policy stakeholders on how that inherent conflict should be managed in an open and liberal democracy.

In 2016, with the encouragement of a wide range of health agencies, the department reported to the World Health Organization treaty secretariat that it had "put in place measures to undertake a review of existing domestic actions, global approaches and opportunities to reinforce and build on current domestic measures." and that details of these actions would be reported in subsequent years. Nothing has yet been reported, although guidance based on international experience is available.

Until these guidelines are in place -- and until publishers like the Globe and Mail and policy-influencers like the CD Howe Institute provide transparency to their readers -- Canadians should continue to be very cautious in receiving the views of those, like Mr. Irvine, whose recommendations are aligned with those of the industry which funds him.


[1] Irvine, I. Ottawa’s tobacco tax should reflect the different health risks of vapes. Globe and Mail. May 9, 2021. 

[2] Ian Irvine. The Taxation of Nicotine in Canada: A Harm-Reduction Approach to the Profusion of New Products. CD Howe Institute. April 27, 2021.

[3] Ian Irvine. Smart Youth Drive Enormous Smoking Declines. CD Howe Institute. March 30, 2021

[4] Ian Irvine. Tobacco Harm Reduction (Part one) - Guiding Principles. CD Howe Institute. Septembef 2, 2020.

[5] Ian Irvine. Tobacco Harm Reduction (Part one) - Nicotine Use in Canada. CD Howe Institute. September 3, 2020.

[6] Ian Irvine. Tobacco Harm Reduction (Part three) - Regulatory Policy. CD Howe Institute. September 4, 2020.

[7] CD Howe Institute. S2 E9 – the Vape Debate with Ian Irvine. June 16, 2020.

[8] CD Howe Institute. Policy Conference. Vaping and E-Cigarette Regulation in Canada. March 2020.

[9] Foundation for a Smoke-Free World. Awarded Grants. BOTEC Analysis, LLC.

[10] Hampsher, S and Prieger J. Investigating the Drivers of Smoking Cessation: A Role of Alternative Nicotine Delivery Systems? BOTEC Analysis for the Foundation for a Smoke Free World, October 2020.

[11] Irvine, I and Hamsher, S. A Multi-Disciplinary Study of the Drivers of Smoking Cessation in Canada. 2020.

Monday 10 May 2021

Why does British Columbia lag behind when it comes to taking cigarettes out of pharmacies?


More than 30 years ago, Canadian health organizations began to campaign for pharmacies to stop selling cigarettes. One by one, 9 provinces and 3 territories amended their tobacco laws to end this practice. Only one province - British Columbia - has firmly declined to take this step. 

This post looks reviews provincial bans on pharmacy sales of cigarettes, and B.C.'s exceptional position to maintain them.

Selling tobacco products is incompatible with the health care responsibilities of pharmacists. 

Pharmacies have been granted exclusive control over the dispensing of many medications and are part of the health care system. Pharmacists are actively engaged in the health of their community. They provide patient counseling, medication therapy monitoring, and help identify and resolve drug related problems.

  • The sale of tobacco in a health care facility such as a pharmacy gives a false and dangerous credibility to cigarettes, and suggests that their use is compatible with health. 
  • Selling cigarettes (that cause disease) is inherently in conflict with the pharmacist’s role in preventing and treating disease.
  • Domestic and international codes of practice for health professionals call on pharmacists to disengage from tobacco commerce.  
Pharmacists need government support to remove tobacco from drug stores

Recognizing this responsibility, pharmacist organizations (including in British Columbia) have adopted policies to support the removal of tobacco from the stores in which their pharmacy practice is located. Because the owners of these stores are not health professionals, but do have responsibilities to generate revenues, the practice standards of pharmacists have not smoothly transferred to the parts of the drug store that surround the dispensing area.

In 1996, for example, the Quebec College of Pharmacists established that their Code of Ethics required that tobacco sales not take place in a pharmacy. Large pharmacy chains, including Shoppers Drug Mart and Jean Coutu, resisted this and took the Order to court. In 1998, the courts upheld the Code of Ethics,  -- and so did the Quebec legislature, which included the sales ban in the Tobacco Act.  (The history is told here on page 174-175.)

Similarly, the Newfoundland Pharmaceutical Association included a sales ban in its Standards of Practice, but found it difficult to enforce. In 2000 the provincial legislature moved to include the provision in its tobacco sales law.

The same challenges have faced pharmacists in British Columbia. The difference is that the B.C. College was unwilling or unable to enforce professional standards on pharmacy-owners and that the B.C. government was unwilling to step in to help them achieve the goals of this standard.

The College of Pharmacists of British Columbia had formally endorsed an end to tobacco sales since 2000, and in 2014, it proposed that this become a new professional standard. As in other provinces, the big pharmacy chains objected and threatened legal action. But instead of the College and the government staring down these business interests, the initiative was dropped. Since 2015 their strategic plan to end tobacco sales has been put on hold.  

Communities support tobacco-free pharmacies

Other Canadian governments have ended pharmacy sales of tobacco with the urging and support of the health community, and without any negative political, business or community response. 

The B.C. government has similarly been encouraged by organizations like the British Columbia Lung Association, the Heart and Stroke Foundation and the Canadian Cancer Society and others. A recent petition campaign led by Leo Levasseur reflects a citizen's frustration with the government's failure to legislate, while rewarding the pharmacy chain that has worked to block reform.

B.C.'s 'harm reduction' lens on pharmacy-sales is not supported by evidence

 In 2014, then Minister of Health, Terry Lake, defended the government's decision to allow tobacco sales in pharmacies as a sort of "harm-reduction" strategy: “You have the opportunity to interact with a health professional about smoking-cessation programs... some have argued that this is such a dangerous substance that it should be sold only in drugstores.”

The idea that ONLY pharmacies or other health-mandated retailers should sell tobacco products has been proposed elsewhere. While this could be a welcome innovation in Canada, the government of British Columbia has not taken any steps towards such a change in tobacco retailing.

Moreover, to date there is no evidence that allowing cigarette sales in pharmacies reduces any harm or increases support for smokers' quitting. Canadian surveys found that smokers were no more likely to report being counselled by a pharmacists in provinces where they could sell cigarettes. To the contrary, U.S. studies have shown that in areas where there pharmacies stop selling cigarettes, there are greater quit attempts.

A change of government did not change B.C.'s policy

Between 2001 and 2017, the Liberal Party held power in British Columbia. Although it introduced restrictions on tobacco sales in 2007 (including banning their sale in hospitals and other health facilities), that government resisted any restrictions of sales on pharmacies.

The New Democratic Party was in opposition during that period, and several of its members pressed for a ban on tobacco sales in pharmacies, through back-benchers motions and petitions. In 2007, the opposition health critic, Adrian Dix, pressed for British Columbia to join other provinces in banning pharmacy sales. “One of the next steps that's required to protect people from the impacts of cigarette smoke is to make pharmacies, which are a place of health, come forward into the 21st century and not allow the sale of cigarettes in pharmacies," he told the legislature. In the first 3 years as Health Minister, Mr. Dix has introduced other important tobacco control initiatives, but has kept silent on the subject of pharmacy sales of tobacco. 

When it comes to tobacco sales in pharmacies, British Columbia remains the odd-man-out among Canadian health authorities. It continues to be out of step with the advice of health professionals  - and in step with the interests of business. 

Wednesday 5 May 2021

TAAT: Another challenge for tobacco regulators

What looks like a cigarette, tastes like a cigarette and smells like a cigarette but is not regulated like a cigarette?

Meet TAAT, a hemp-based cigarette look-alike. Made by a Canadian company, designed by Philip Morris International alumni, and now being test-marketed in the U.S.A., TAAT are nicotine-free 'cigarettes' that promise a realistic smoking experience. And, yes, the company has announced its plans to sell them in Canada.

The selling proposition:

No nicotine. All flavour. Beyond tobacco. These cigarettes are marketed to consumers as a celebration of smoking without the head-rush: "Between the tobacco-like taste and smell of the Beyond Tobacco™️ base material, the sight of smoke, the “crackling” sound of TAAT™ burning, and the physical sensations of inhaling and exhaling as well as flicking ashes, no detail has been overlooked in creating a satisfying experience for smokers."

Just as the hemp has been modified to maintain and reinforce the distinctive tobacco smoking experience, the marketing is designed to maintain and reinforce the iconoclastic imagery of cigarette smoking. TAAT's retro-hipster ads evoke a time when cigarettes were uncomplicated by health considerations, and they model defiant attitudes about smoking. 

Another off-shoot of Big Tobacco

TAAT cigarettes blur the lines between cannabis- and tobacco-products. This is not the first company to enter this space. As discussed in a previous post, British American Tobacco is currently test-marketing CBD pods for its vaping products, and Philip Morris has also signalled its intention to go "beyond nicotine" into other (yet unspecified) botanicals. As with these other ventures, TAAT is an expansion of the tobacco trade: The people behind TAAT were until recently developing Philip Morris products and distribution systems

Another 'harm reduction' commercial product

These cigarettes are yet another attempt to gain commercial advantage from harm reduction. Like vaping products, heated tobacco and modern oral, hemp cigarettes (and oral hemp), are marketed as a way for smokers to change their drug use without abandoning it. Commercialized harm reduction is running in two directions: e-cigarette manufacturers make money by encouraging people to access nicotine without tobacco, and TAAT offers hemp for those who want to smoke while avoiding tobacco and nicotine.

Canada's TAAT-friendly regulatory environment

TAAT is headquartered in an industrial park in Toronto (345 Horner Avenue, Toronto, ON M8W 1Z6) and its official address  (Suite 180-789 West Pender Street) is shared with a number of resource extraction and cannabis companies, including its Canadian distribution partner, Christina Lake Cannabis.

Its recent annual report (filed last month with SEDAR) reports that this company was recently grafted onto the roots of a failed venture in resource extraction: "The Company was incorporated on June 5, 2006, in British Columbia under the Business Corporations Act (British Columbia). The Company was historically in the business of exploring for or purchasing economically viable oil and gas resource deposits. On October 31, 2018, the Company suspended substantially all production operations as a result of extreme volatility within the commodity markets, regional supply and demand and decided not to proceed with these leases and as a result the oil and gas operations have been recorded as discontinued operations. In January 2020, the Company ceased to carry on its business as an oil & gas exploration company, and changed its principal business to the manufacturing and distribution of a nicotine-free and tobacco-free alternative to tobacco cigarettes that has been developed to closely mimic the experiential components of smoking legacy tobacco products."

TAAT is listed on the Canadian Stock Exchange, a regulation-light alternative stock market that offers "reduced barriers to listing." Because Canadian security laws make it easier for this company to raise the capital to sell these products, and impose fewer reporting requirements on it. 

Cracks between Health Canada's regulatory systems

Smoking products that do not contain tobacco or nicotine or cannabis (like herbal cigarettes or herbal shisha) are considered consumer products and are subject to the federal Consumer Product Safety Act. Although this law forbids manufacturers from selling products that are "a danger to human health or safety", this prohibition is applied only with respect to immediate danger. (On this basis, the department rejected the 2013 request by Physicians for a Smoke-Free Canada for controls on herbal shisha.)

Herbal cigarettes are regulated by Health Canada - but not in the context of tobacco control. 

Smoking products that do not contain tobacco or nicotine or cannabis (like herbal cigarettes or herbal shisha) are regulated as consumer products and are subject to the federal Consumer Product Safety Act. Although this law forbids manufacturers from selling products that are "a danger to human health or safety", this prohibition is interpreted as causing immediate danger. (In 2013, Physicians for a Smoke-Free Canada provided Health Canada with evidence of the dangers associated with smoking shisha and unsuccessfully requested that the government require the product to be withdrawn from the market.) 

Smoking products that contain hemp are subject to the federal Cannabis Act and its regulations for industrial hemp, and also to any provincial regulations on the sale of hemp products. Christina Lake Cannabis Corporation, which will be developing and distributing TAAT cigarettes in Canada, has informed investors that currently holds the license to do so. "CLC’s status as a Licensed Producer under the Cannabis Act could enable TAAT to be produced and sold in the Canadian market... Although CLC does not presently cultivate hemp, the Company has sourced multiple local growers who can supply high quality, toxin-free hemp biomass."

Herbal cigarettes that are marketed as cessation products are subject to the Natural Health Products Regulations. Because TAAT is marketed as a harm reduction product and not a cessation aid, these regulations are unlikely to apply. 

Health Canada has acknowledged that herbal cigarettes are unsafe products  ("Health Canada does not recommend using these cigarettes as a long-term alternative to tobacco cigarettes due to the danger posed by the inhalation of smoke of any kind.") and reports that it is "tracking the use and sales of these products to determine the level of use, changes over time and whether any action is required."

TAAT's advertisers face few regulatory barriers in Canada.

TAAT products are currently advertised in the USA through lifestyle ads, testimonials and event sponsorships - promotions that are illegal in Canada for cannabis or tobacco products. 

Because they are hemp products, it appears unlikely that TAAT cigarettes will be subject to advertising restrictions, such as those for tobacco products, for non-hemp cannabis products or for therapeutic products. At a federal level, the only prohibition is that they cannot be marketed as having psychoactive properties.  At a provincial level, only Quebec has a tobacco law designed to include products other than tobacco cigarettes. (Regulations under Quebec's Tobacco Control Act establish that "for the purposes of the Tobacco Control Act (chapter L-6.2), any product that does not contain tobacco and is intended to be smoked is considered to be tobacco.")

Tuesday 4 May 2021

Is there any public health benefit to menthol-flavoured vaping liquids?

This post reviews the rationale for banning menthol flavourings in vaping liquids.

Background and context

Since the legalization of vaping products as unlicensed consumer goods in May 2018, the use of these products by young Canadians has grown rapidly, and concerns have increased about their usefulness as cessation aids or harm reduction products.  

Because flavourings are one of the major reasons young people say they use vaping products, many Canadian governments are considering restricting or banning flavourings in vaping liquids. Five jurisdictions (BC, SK, ON, NS, PEI) have implemented restrictions on flavoured vaping products, and two more (QC, PEI, NWT) have indicated their intention to do so. 

A variety of regulatory approaches are being explored and implemented. These include:

  • Banning characterizing flavours and/or banning specific additives.
    Two provinces (Nova Scotia and Prince Edward Island) ban all flavours except tobacco flavour. Nova Scotia's measures came into force on April 1, 2020 and PEI's came into force in March 2021. The federal Tobacco and Vaping Products Act currently prohibits the promotion or sale of vaping liquids with names that are associated woth confectionary, deserts, cannabis, energy drinks or soft drink. It also bans certain additives in vaping liquids (caffeine, dyes, nutrients, vitamins, glucuronolactone, taurine and probiotics). The federal government has indicated that it will develop additional restrictions on vaping liquids this spring, as has Quebec.
  • Restricting where flavoured vaping liquids can be sold 
    Two provinces (Ontario and Saskatchewan) have adopted policies to allow non-specialty stores to sell only two flavours: tobacco and menthol. One province (British Columbia) allows non-specialty stores to sell only tobacco flavours. The sale of other flavours is permitted on-line or in specialty stores in these 3 provinces.

The number of flavours in youth-friendly products is growing

Unlike other countries (like the European Union), vaping manufacturers are not required to provide notice to the government of the products that they sell. As a result, there is no Canadian inventory of the vaping flavours currently on the market. 

Nonetheless, the product offerings of the 3 multinational companies (JUUL, BAT-VUSE, JTI-Logic) show that for these top-selling youth-friendly products there are a multitude of flavour offerings in each flavour category.  Just as cigarettes are sold in brand extensions (Players, Players Bold, Player's Smooth, etc), vaping products have more than one option in each flavour space. Just as cigarettes were sold with an expanding range of sub-brands, vaping products are sold with an expanding range of sub-flavours

  • BAT sells 22 flavours, including 4 variants of tobacco flavouring and 3 mint-menthol flavours
  • JTI sells 11 flavours, including 2 tobacco flavours and 3 mint-flavours
  • JUUL sells 3 flavours, including 2 tobacco flavours and 1 mint flavour (it withdrew other flavours from Canada in 2020).
The number of flavourings offered by some companies is growing, and is greater in Canada than in other countries for the products sold here

 Menthol is a preferred flavour of young vapers 

Over the past few years, Health Canada has conducted a number of consumer studies on vaping behaviour in Canada. 

  • The Canadian Tobacco and Nicotine Survey, 2020
    Data from the first wave of the cross sectional Canadian Tobacco and Nicotine Survey, taken in the fall of 2019, has been made available by Statistics Canada for external analysis (and the second wave is expected to be released later this spring). This survey found that fruit and menthol were the first and second choice flavours for young people. So few young people said they usually smoked tobacco flavour that the results were deemed "unreportable" (#). The selection of menthol by those over 25 years of age was similarly too small to report.  
  • Environics Vaper Panel is an on-line return-to-sample survey commissioned by Health Canada. In the spring of 2020 (POR 098-19) the flavour preferences of regular vapers (those who had vaped at least once a week in the past month) were revisited. Fruit and menthol were found to be the favourite flavours of young people. (Chart below taken from data tables)

  • The Environics research also found some regional differences: Menthol flavourings were more popular in Quebec and Fruit flavourings more popular in the Atlantic Provinces (the survey was taken before Nova Scotia's flavour restrictions were implemented.

  • Research conducted in 2020 and 2021 by Mohammed Al-Hamdani and colleagues with the support of the Lung Association, Heart and Stroke Foundation and provincial tobacco control commissions produced similar results. In an on-line survey of more than 3,000 Canadian youth and young adults, aged 16 to 24, very few identified tobacco as their most used flavour. The most popular flavour categories fruit (berry and mango) and mint-menthol. 

  • Canadian research, as shown above, is consistent that the only flavour not preferred by young people is tobacco flavouring

Menthol-flavouring ingredients make e-cigarettes more addicting.

With the benefit of mandatory European ingredient reporting, Dutch researchers [1] were able to identify which vaping flavours contained chemical menthol and also which additives were included in menthol-flavoured vaping products. This information is helpful to the two main regulatory approaches to restricting flavours: a) prohibiting the use of certain additives (eg. Health Canada), b) prohibiting the use of characterizing flavours (eg Nova Scotia).

From this very European analysis, the 6 major flavourings in vaping liquids labelled as menthol or mint were menthol (59% of liquids; median concentration of 57 mg/10ml), menthone (17%; 23 mg/ml), ethyl maltol (13%; 0.74 mg/10ml), vanillin (12%; 1 mg/10ml), eucalyptol (11.5%; 7 mg/10ml) and peppermint oil (11%; 10 mg/10ml). 

The researchers conclude that these (and other) flavour ingredients are found to increase the addictiveness of e-cigarettes because they   
"enhance the rewarding and reinforcing effects of nicotine in e-cigarettes in young adult smokers. [60, 61] For example, menthol and the green apple flavoring, farnesene, facilitate nicotine dependence through upregulation of nACh receptors in the brain [62,63]. Furthermore, flavorings reduce the nicotine metabolism (e.g., menthol, cinnamaldehyde and benzaldehyde) [64,65] and are known to facilitate inhalation and nicotine uptake due to their cooling and bronchodilating effects (e.g., menthol, theobromine and eucalyptol) [62.] In addition, flavorings such as vanillin, ethyl vanillin, and coumarin inhibit monoamine oxidase enzymes, which results in a delayed degradation of dopamine in the brain, an extended feeling of pleasure, and an increase in reinforcing behavior 66,67. ....In summary, flavors stimulate palatability as well as reward from nicotine in e-cigarettes, and, hence, contribute to nicotine dependence not only through their physical properties (e.g., cooling) but also through their history of associative learning."

Health Canada has previously acknowledged this. When publishing its 2017 regulation to ban menthol in cigarettes, it reported: "Menthol in tobacco products has numerous pharmacological effects, one of them being to mask the irritating effect of tobacco smoke, making it easier to inhale, which facilitates experimentation among novice users. Promoting experimentation among youth increases the potential for continued tobacco use that leads to addiction and an increased risk of tobacco-related diseases."


[1] Erna JZ Krusemann. The role of flavours in attractiveness of electronic cigarettes. PhD Thesis, 2021.