Health Committee on Oct. 28th, 2014

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you.

Dr. Britton.

[Dr. John Britton]

Well, I would say that your son is not addicted to two products. He's added to one thing, which is nicotine, and he's finding it from wherever he can get it, so the more alternative sources of nicotine there are out there for him, the better.

Being a smoker is like being trapped in a nightclub when a fire breaks out. You need as many exits as possible, and it doesn't matter which one you use.

However, dual use is common with these products, just as dual use is common with medicinal nicotine. But what we do know, and the British National Institute for Health and Care Excellence has accepted this in its guidance on harm reduction, is that dual users are much more likely to quit smoking completely than people who never experiment with an alternative nicotine product. So the outlook for your son is good: he's going to quit, but it may take him a year or two to get around to it. That's the reality.

The strength of electronic cigarettes is that it draws people like your son to try nicotine products, people who otherwise wouldn't. The history of NRT is that it's used by a small minority of smokers, and electronic cigarettes by a much greater proportion.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you very much.

Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair.

Thank you for being available to us to answer some questions.

I would like to ask a couple of questions. I think the argument that we have not actually seen whether or not these e-cigarettes would lead eventually to most cigarette smokers quitting was clearly stated by the World Health Organization, Dr. Peruga. There is no evidence yet, although in your report you said the only one that showed there was a rise in use of these cigarettes among people who had not used cigarettes before was in Poland.

The question I want to ask is this. As you know, as physicians, normally when we try to get someone off cigarettes, we're using the nicotine patch, the gum, etc. Now, that's nicotine the people are using, so here's my question for you, just for the sake of clarity. If you do not have a combustible source for nicotine, such as a cigarette, with the tar, the benzopyrenes, and all of these things that create cancer and COPD, etc., what inherently is the risk of simple nicotine addiction?

[Dr. John Britton]

I can start with an answer to that if you would like.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Yes, Dr. Britton. Go ahead.

[Dr. John Britton]

The evidence in clinical trial evidence is that nicotine is not particularly hazardous. It's not associated with an increased risk of cardiovascular disease. It does things to the human body that are probably on a par with caffeine.

The best long-term evidence on the hazards of long-term nicotine use without combustion is the evidence from exclusive users of smokeless tobacco in Sweden, who do have a possible increased risk of esophageal cancer and cancer of the pancreas, though those things may well be due to nitrosamines in tobacco that they're swallowing.

But the other disease risks—lung cancer, COPD, and cardiovascular disease—are just not substantially increased. For cardiovascular disease, there's a slight signal. For COPD and lung cancer, there is nothing.

I think we can conclude from that experience that the hazards of regular nicotine use to a healthy person for a lifetime are, if not trivial, close to it.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

Dr. Peruga, do you have anything to add?

[Dr. Armando Peruga]

Yes. I agree with many of the things that Professor Britton has said. In terms of the risk of nicotine, it's not the killer in tobacco. However, I think it has not been researched thoroughly in some aspects.

We know that nicotine seems to play a small role as a tumour promoter, but the main concern, I would say, as indicated by the Surgeon General's report of this year, is the access to nicotine by young people in phases in which their neurological system, especially the brain, is not fully matured, and how that can have an impact on the brain's development, leading to some issues of learning disabilities. The report of the Surgeon General of the United States made a strong point about this being a concern. That's why the concern in regard to nicotine is about youth, mainly—and, obviously, pregnant women—not necessarily adults.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Could that be rectified by bringing in regulations that have an age limit for access to any form of nicotine whatsoever, especially on e-cigarettes? Therefore, there would be an age limit for youth—if you looked at regulations.

[Dr. John Britton]

Could I comment on that?

I agree with Dr. Peruga that none of us would want our own children or anybody else's children to be using nicotine as primary users, as new users, but I don't know what the prevalence of smoking in young people is in Canada. In my country, by the time people reach the age of 24, 40% have been smokers and about 25% are regular smokers. So kids from disadvantaged backgrounds, where cigarettes are lying around in the home as they grow up, are already being exposed to high quantities of nicotine at very important stages of brain development. The more that we can substitute clean nicotine products for the dirty stream of nicotine delivery—which is tobacco—the better.

Whilst I entirely agree that limiting access to young people is probably a good thing, particularly if we have young people who are otherwise going to smoke, it would make far more sense to have them use an electronic cigarette.

[Hedy Fry, Liberal, Vancouver Centre, BC]

May I ask one other question? Is it possible to bring in a regulation that prohibits tobacco companies that already make cigarettes from actually producing e-cigarettes or the vaporized form of that? How can one do that? Can you do that, in other words, so that you stop them from benefiting from introducing it to a whole new generation of users?

[Dr. John Britton]

I think the answer to that question really depends on what your target is. If your target is stopping the tobacco industry from profiting any further, then you might take that move. If your target is to stop people smoking cigarettes, then we need to look at the products, not who makes them.

I quite accept and I share many of Dr. Peruga's concerns about the tobacco industry. I'm no apologist for that industry, but I do think we have to remember that our objective here is to prevent premature deaths in smokers, not to put the tobacco companies out of business. I don't actually care who makes the products, so long as they work.

[Dr. Armando Peruga]

However, I may say that I would be naive to consider that the product and who makes it are two separate and completely independent issues. How they manage their different portfolio of products is part of the tobacco industry's strategy. Who makes them and what they make are inseparable in many ways.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

[The Chair, Conservative, Ben Lobb]

For seven minutes, Ms. Adams.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you, Mr. Chair.

In Canada smoking is at an all-time low. We've dropped from 22% to 16% in the last decade.

We're obviously primarily and especially concerned with adolescents taking up smoking, because it does lead them onto a path of lifelong smoking—but smoking by them is also at record lows. We're only at 7%. Of Canadians aged 15 to 17, only 7% smoke. I believe that on an international basis we're leading the world in banning flavoured cigarettes, and we prohibit companies from advertising directly to children.

I want to follow up on the concern of one of my opposition colleagues about smoking e-cigarettes with or without nicotine in public places. I guess my concern is twofold. One, even if there is nicotine in that e-cigarette, I am less concerned about the fact that there is a dramatic decrease over combustible cigarettes, because I think the expectation that Canadians ought to have, certainly for ourselves and for our children, is that they should be in smoke-free environments altogether.

Additionally, I think we also want to de-normalize smoking. Children are particularly susceptible to social cues, so if they just see the behaviour.... You can remember that entire concept that smoking in movies just seems rather cool, or the fact that it seems rather normal that you would be out in a restaurant, a public place, or a place of work and people are out there smoking an e-cigarette, with or without nicotine. I think it sends a terrible message to youth, and I think we want to de-normalize that.

I think that's a separate conversation, though, from whether or not we want to offer adult choices to folks and provide e-cigarettes for sale in Canada with nicotine content. I would hope that as a nation we would encourage those who ban cigarettes currently from banning all e-cigarettes, with or without nicotine, because I think we genuinely do want to target adolescents and ensure that they aren't picking up on this habit and that we're not normalizing it.

Would you have any comment, though, on the concept of e-cigarettes with nicotine and ensuring that we have smoke-free places as opposed to just lowered output? Currently in Canada, we're banning that. You can't just go and smoke in a restaurant. I'm very concerned that you would be recommending that there isn't much harm there. Could you perhaps extrapolate?

[Dr. John Britton]

Canada has indeed brought in tobacco control policies that are the envy of the world. You and one or two other places are beacons of achievement in reducing smoking prevalence. We aspire to that.

In Britain we have a complete smoke-free policy for all enclosed public places and workplaces. We haven't gone down the route of banning electronic cigarette use by law in those circumstances.

The argument, as you've pointed out, has two sides to it. On the one hand, we want to protect our children, but on the other hand, exposing children to clusters of smokers outside the buildings and seeing smokers out in the street normalizes the behaviour of smoking, whereas seeing people using vaporizers arguably normalizes the use of vaporizers. Now, that's not say that I want children to grow up aspiring to become a vaporizer user, but I would much rather they aspire to that than aspire to being a smoker.

I think it's quite a difficult balance. The way that I've argued it in the U.K. is that for the most part where smoking is prohibited, so should electronic cigarette use, but it should be a matter of courtesy, not law.

But there are certain circumstances where indoor use would make sense. In that, I would include some hospital areas—for example, mental health settings, where in Britain the smoking prevalence is extremely high—and also the situation I have in my own clinical practice. As a chest physician, I know that my patients are using electronic cigarettes under the covers of the bed because they've been told they can't use them indoors. I think we need to make some system that accommodates that need, rather than have them get out with their drips to go and stand outside and smoke in the rain.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

You mentioned earlier that Europe was about to bring in regulations for e-cigarettes. You indicated that you weren't certain what the permissible nicotine content would be. Can you perhaps refer me to some papers that were under consideration?

[Dr. John Britton]

The tobacco products directive was published earlier this year. To find it you can just search online for the European Union's tobacco products directive. Dr. Peruga might be more familiar with the chapter and verse of it.

I can't remember what the upper limit on nicotine content was, but it was extremely low.

[Dr. Armando Peruga]

I would just add that the tobacco products directive separates products. Those that contain nicotine of up to 20 milligrams per millilitre would be regulated under the tobacco control legislation. For those that go over 20 milligrams per millilitre of nicotine, the recommendation is that they should be regulated as medicinal products. That's according to the tobacco products directive.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you.

To your knowledge, what are the best practices currently on providing for the sale of e-cigarettes? We, for instance, obviously regulate even our local convenience stores, which need to ensure that people are able to produce ID. People need to be over the age of 18 in order to purchase cigarettes.

What is the best practice that you are aware of internationally for e-cigarettes?

[Dr. John Britton]

If I respond to that first, I think something very similar.... It's difficult, because as I've already argued, I would prefer that teenagers experimented with electronic cigarettes than real cigarettes. At the same time, I think we have to have restrictions on sales below the age of 18. In England there is a law coming through to deal with that.

So far, however, it has to be said that, with the exception of the Polish data that Dr. Peruga referred to, which also showed a 60% increase in smoking in a three-year period—rather larger than I could believe, because the samples were not taken from the same sources on the separate occasions—the availability of electronic cigarettes hasn't led to a huge increase in use among young people who are not smokers.

So it makes sense to have restrictions in place, but I wonder if they're necessary.

[The Chair, Conservative, Ben Lobb]

Thank you.

We'll now go to Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

First of all, it's been a very interesting discussion to hear your perspectives.

I'd just like to go back to Professor Britton and speak about the experience in the U.K. I do think there's a lot of mythology around addiction. The stuff that I've read argues that probably the most common and one of the most powerful addictions, which you alluded to, is caffeine. In fact withdrawal from caffeine is very, very severe, as anyone who has tried it will know. Yet it's so culturally accepted in our society that we barely talk about it. So there is relativity in this discussion.

I'm very curious to know about the British experience in terms of how the debate went politically. You speak about harm reduction, risk minimization, and how less is better than more; e-cigarettes are better than people smoking outright combustible cigarettes and so on. Yet in the debate we have here, there's a great fear about a harm reduction approach. It has almost become a bad terminology to use. We keep coming back to this notion that it's only zero tolerance and prohibition, which to my mind means chaos, and that it's somehow a better approach. I don't subscribe to that myself.

I just wonder about how the debate went politically. You talked about two different governments that adopted this approach. What was the debate like in the U.K. around e-cigarettes and from a harm reduction point of view?