The debate, sometimes passionate, often stormy, around the risk-benefit ratio of electronic cigarettes, seems set to last. Since its invention some twenty years ago, vaping has been far from unanimous among health authorities. It must be said that the arguments of supporters and detractors of heated e-liquids remain legitimate. Decryption…
Twenty years after its invention, the electronic cigarette has failed to obtain the approval of the Ministry of Health as a smoking cessation aid. Yet successive governments since the early 1980s have spared no expense in ridding France of its unflattering nickname "Europe's Chimney". At issue:a lack of glaring data on the impact of vaping over the long term, but also a fear that the electronic cigarette will serve as a gateway to smoking among the youngest. It must be said that the perfumes and other flavors offered by the manufacturers can appeal to a target that was not necessarily predisposed to suffer from nicotine addiction.
That being said, there are voices advocating a “lesser evil” policy, and there too, the arguments are legitimate. According to a study published by Public Health France on June 26, 2019 (see the article in Le Figaro on this subject), the e-cigarette helped some 700,000 French people to quit tobacco between 2012 and 2019. A performance that goes beyond far, that of classic nicotine substitutes such as patches and gums. The National Academy of Medicine, which takes advantage of an empirical approach, does not hesitate today to encourage vaping as part of smoking cessation. The more cautious Haute Autorité de Santé (HAS) "does not recommend electronic cigarettes", but believes that its use in smokers who wish to quit "should not be discouraged".
Health actors who are not fundamentally "anti-vaping" agree on one position:the electronic cigarette can only be considered in the context of smoking cessation. The use of a vaping device by smokers must imperatively induce, if not a total cessation, a significant drop in tobacco consumption. Combining electronic cigarettes and tobacco without bringing about a drastic reduction would induce an exacerbation, then an aggravation of the addiction.
Based on this observation, the electronic cigarette should in no way be considered as a recreational object for non-smokers. To extend the point, health actors who do not deny the interest of e-cigarettes in the fight against smoking are de facto against flavored e-liquids, which increase the risk of recreational use. Indeed, only the tobacco flavor would be "legitimate", both to promote gradual weaning, but also to limit the risk of recreational use motivated by trying the flavors and flavors offered on the market.
Be that as it may, and despite a tendency to de-demonize the electronic cigarette as a smoking cessation tool, the Ministry of Health does not include the electronic cigarette in its arsenal in the fight against smoking. , which remains driven by awareness campaigns, the reimbursement of "approved" nicotine substitutes, the gradual increase in the price of a pack of cigarettes and the ban on smoking in public spaces.
Nevertheless, we can observe here too in the ministry a less and less virulent discourse. "Between 1.1 and 1.9 million people use electronic cigarettes daily in France:67% of these are tobacco smokers, who use it mainly to stop or reduce their daily consumption. , and therefore potentially the health risks associated with smoking reads the Ministry of Health's "Electronic Cigarette" page.
In the classic cigarette, most of the harmfulness results from the combustion of the tobacco. It is indeed this phenomenon which is responsible for the inhalation by the smoker of toxic and potentially carcinogenic substances such as carbon monoxide (CO), volatile organic compounds (ketones, aldehydes, ammonia, hydrocarbons), tar (benzopyrenes and anthracenes mainly), and other problematic particles such as nitrate derivatives, heavy metals (especially cadmium), free radicals and even radioactive products (in the form of traces).
The e-liquid is to the electronic cigarette what tobacco is to the classic cigarette. It is therefore quite natural that the main fears about the harmfulness of the vaping device are directed towards this liquid. The major challenge here is to assess as precisely as possible the benefit-risk ratio of the e-liquid heated in the vaping device. For the analysis not to be biased, it must be kept in mind that this is a comparative work, where the benefits and risks of heated e-liquid are systematically put into perspective with the effects of burnt tobacco. To fully understand each other's positions on the issue, it is necessary to explore the properties of heated e-liquid, its "benefits" over tobacco, but also the risks specific to it.
In any case, this is what emerges from the press kit produced by the National Agency for Food Safety, Labor and the Environment (ANSES). We learn, for example, that 75% of e-liquids marketed in France are of French or European manufacture. The agency, which offers an unprecedented reference list listing the chemical composition of ALL e-liquids marketed in France, delivers the following conclusions:
ANSES is content to analyze the composition of cold e-liquids. To go further, we consulted the data from the study carried out by the Center for Research and Innovation for Vaping (CRIVAPE). Heated e-liquids contain, on average, a few micrograms of carcinogenic substances for 200 puffs, a value well below the French experimental standards of the French Association for Standardization (AFNOR). In comparison, a study by the French Office for the Prevention of Smoking estimates the concentration of formalin (alone) at 3 mg per pack of cigarettes. Remember that tobacco smoke is made up of several thousand chemicals, of which more than fifty are classified as "carcinogens". In reality, the complete chemical composition of tobacco smoke is not yet known exactly.
Also, the opinion issued by the National Institute for Research and Safety on propylene glycol, omnipresent in the composition of e-liquids, agrees. The Institute, which recalls that this substance is also present in certain foods, medicines and cosmetic products, considers it "non-toxic". Consequently, the “lesser evil” approach advocated by “Les Sages” of the National Academy of Medicine seems legitimate. Concretely, and if we base ourselves on a simple substitution of tobacco by the e-cigarette, even in the absence of a desire to stop inhaling nicotine, the vaper is de facto spared from tar, carbon monoxide and other carcinogens found in tobacco smoke. On the other hand, and as you will be able to see, the field can experience other realities...
To properly measure this risk, we offer you the study of a concrete case. In September 2019, the US Centers for Disease Control and Prevention (CDC) warned of a nationwide outbreak, with an outbreak in New York State, of a lung disease severe, with patients usually presenting within days to weeks of the onset of respiratory symptoms. All the cases of this disease described as "mysterious" in the media involved patients with a history of use of electronic cigarettes or other vaping products. As of February 4, 2020, 2,758 cases of this pathology retrospectively called "Evali" have been identified in the United States, with 64 confirmed deaths.
Extensive investigations by the federal health authorities have made it possible to precisely define the cause of this serious pneumopathy. The overwhelming majority of patients admitted to hospital had vaped adulterated e-liquids and/or containing tetrahydrocannabinol (THC), the main active molecule in cannabis. Note that this substance "benefits" from a loophole in the French public health code, making it theoretically legal since 2007. The US CDC's final report explains that "recent national and state findings suggest that products containing THC, particularly from informal sources such as friends, family, or dealers, are linked to most cases and play a major role in the epidemic .
Vitamin E acetate, contained in e-liquids vaped by patients, also seems to play a role. A conclusion shared by the French National Academy of Medicine in its communication of December 12, 2019:"the American epidemic of lung damage is due to a diversion of the use [of the electronic cigarette], because after having questioned vaping as such, the Center for Disease Control and Prevention and the Food and Drug Administration recognize that this diversion is the main cause of this epidemic ". And to continue:"we must not accuse the container of being harmful when it is the content that is actually harmful and responsible for the American alert .
While this serious epidemic is not consubstantial with vaping as such, it underlines the vital importance of guaranteeing consumers flawless traceability of the e-liquids marketed. In short, it will be a question of equipping them to answer the fateful question:what are liquids for electronic cigarettes made of? This is undoubtedly what prompted ANSES to set up an exhaustive database open to all, listing the chemical composition of all e-liquids whose marketing is authorized in France.
French vapers must therefore do research to ensure the indexing of e-liquids before purchase. This precautionary measure is all the more imperative as ANSES reports inconsistencies and non-conformities between the actual chemical composition and that which appears on the packaging and product sheets. “the Agency has highlighted non-compliances relating to emissions above the regulatory threshold for certain cigarettes or an excessively high concentration of nicotine in certain vaping products .
Studies that have looked at the long-term impact of e-cigarettes generally have two weaknesses:
For some health professionals, the question of the long-term health impact should not be overestimated. Indeed, the electronic cigarette must be exclusively considered as a temporary smoking cessation device that accompanies the smoker in his quest for a tobacco-free and nicotine-free life. The vaping device therefore does not have to be evaluated over time. It remains to be seen whether the temporary use of the electronic cigarette does not result in serious health effects several years after the actual consumption.
