First of all, thank you so much. It's an honour and a pleasure to present to this committee again. I am speaking on the use of electronic nicotine delivery devices, commonly known as e-cigarettes.
We have sent some speaker's notes to you. I'm sorry they came at the last minute, but they have been sent.
Very quickly, the title of my presentation is “E-Cigarettes: Disruptive Innovations with Promise and Peril”. I think that's the reason why we need to look at this.
By way of background, I'm a physician who works at the Centre for Addiction and Mental Health. I specifically focus on the treatment of people with tobacco addiction and am currently also running some studies looking at the use of electronic cigarettes by Canadians.
The big problem is that we are stuck in tobacco control in Canada. For example, cigarettes were actually invented over 150 years ago and the technology hasn't changed that much. What has changed is the ability for tobacco companies to mass produce them and cause lots of harm.
The other reason that we are stuck is that the prevalence of smoking has not budged much in the last five years. Currently, the burden of smoking is borne by people who can least afford to smoke, those who have less than high school education, those who have other comorbidities, like mental health and other addictions. The rest of society has benefited from the existing policies, but there's an inequity that has crept into society where approximately 4.5 million Canadians still use tobacco on a regular basis.
We are stuck. We need new innovations and new ways to address it. We've looked at other mechanisms like education, taxation, and smoke-free by-laws. All of those things have been very useful, including creating treatments for smoking cessation.
However, with the advent of e-cigarettes, or electronic cigarettes, as delivery devices that came onto the market, we began to see great demand by smokers. When you spoke to them, they would say to us, “Well, I'll use it when I can't smoke”. On the other hand, many people were looking at it as a way to get the monkey of combustible tobacco cigarettes off their backs. Again, many people believe that it would be safer and less addictive.
When you look at them, not using a scientific approach but a common sense approach, automatically one can say that they appear to reduce harm and the cost. For example, we know they have lower numbers of particles compared to combustible cigarettes. The risk reduction level is not yet fully known.
On average, definitely, smokers are getting much less chemical exposure than they would from cigarettes. And of course, from a cost perspective, approximately, at least in the U.S., what people can get from one e-cigarette is essentially the equivalent of one to two packs per day. So definitely, it becomes much cheaper for them to use.
However, there are some health risks that are emerging that we need to pay attention to. Whether the e-cigarette contains nicotine or not, there are some problems. They come from the device itself and how it's manufactured. If the battery is faulty, for example, fires can occur. They can overheat, and we've seen some examples of that.
If there isn't any safety coating around the heating element you may be aerosolizing or putting heavy metals into people's lungs. With the newer devices that actually can heat up to higher temperatures we may be actually even creating some cancer causing chemicals that are getting into the person's lungs and body.
The other thing that is the big unknown is the propylene glycol. Although it's generally considered safe in humans, it's not necessarily proven to be safe in this repeated exposure that some people might get. But what we do have are increased cases of poisoning, especially in the U.S., where children have been getting their hands on the nicotine cartridges or refillable cartridges and getting toxicity. Of course, there's the issue of second-hand vapour.
Basically, the studies that have been done to see whether e-cigarettes could be a good smoking cessation alternative similar to the medications for smoking cessation are not as good, or are an equivalent at best. E-cigarettes just cannot compete with cigarettes. The switchover is still not complete because many people will use both cigarettes and e-cigarettes.
I think you are going to hear this metaphor many times from some of my colleagues as well. When both products are on the market, people will go to what they know. So that is one of the problems.
We have had examples in Canada. For example, when we had leaded gasoline and had to move to unleaded gasoline, we had to make some really significant shifts and not have leaded gasoline available at the same time as having unleaded gasoline available. Similar things happened with leaded and unleaded paint. So we have a history of making things safe by removing some toxic chemicals. But you can't have both on the market at the same time.
So the story is not completely told around whether e-cigarettes can be useful to quit smoking when you still have cigarettes available on the market.
The biggest concern we have now, especially in Canada, is that because e-cigarettes not containing nicotine are available in any general store with no age restriction, even my five-year-old could walk up to a store and purchase them and practise smoking without any regulatory framework as to what's in that product or whether it has nicotine or not, contaminations, viruses, or bacteria.... We have no idea what people are getting exposed to. There is no quality control or disclosure of contents and even from the same manufacturer from brand to brand we have no way of knowing what's in that e-cigarette.
Currently I am analyzing an e-cigarette that was bought so-called legally by a patient of a family doctor in our community. That person ended up with headaches, vomiting, nausea, and went to the emergency room where, when they tested him, found that the e-cigarette contained marijuana. We are doing further tests to see if in fact that is true, as we certainly have seen the devices and how they can be manipulated to deliver marijuana instead of nicotine.
So we also have this illogical regulation in Canada where e-cigarettes containing nicotine are not legal, but yet neither are they illegal. So basically we know of people who are using home-grown labs to make nicotine or are importing nicotine and then compounding it and selling it because it's not technically illegal to do that. People are easily converting their devices to use nicotine or marijuana.
What are the challenges and concerns we have? One is that this is potentially introducing youths to nicotine addiction. They are overdosing. The e-cigarettes have flavours and there is advertising for them. Although the U.S. data is comforting in suggesting that e-cigarettes may not be leading kids to go on to full-blown smoking, it is still unclear. There is a great potential for that happening.
The biggest concern currently in the absence of regulation is that we are re-normalizing smoking. So many of you, if you have travelled, may suddenly be surprised to see somebody in a restaurant or an airport lounge “vaping” an e-cigarette. Although it may not results in exposure harm, it is socially harmful because it re-normalizes the act of smoking and makes cigarettes attractive and, therefore, it becomes impossible or very difficult to enforce all the gains that we've made in tobacco-free policies.
The other thing that we've noticed is that it undermines people's efforts to quit smoking, because the attractiveness of this moves them away from approved medications or approaches that have been shown to have benefit towards these issues. I guess the biggest unknown question is the long-term health effects, although from a common-sense approach these would definitely be a lot less than cigarettes. Where the long-term harm might occur is if e-cigarettes become a gateway to people then going on to smoking combustible cigarettes.
If in fact we had a situation where people only used e-cigarettes without going on to other forms of cigarettes, then that would be a different matter. But with the availability of cigarettes and the regulations around cigarettes, the market could certainly get pushed using e-cigarettes as a way of getting a whole new generation of so-called replacement smokers for those who have quit or die off. It becomes very challenging to then have a consistent message to people about tobacco control.
However, having said all that, in the short term I'm going to start off with my eight recommendations that we should think about for the long term and the short term.
In the long term, we have to ask ourselves as a society whether we want to have technology that was developed 150 years ago, that has been proven to kill one-half of its users if used as intended by its manufacturers, to continue to be on the market, or do we owe it to the next generation, when we have a potentially viable alternative because of the development of technology, to study it and look at it as a possible way to replace cigarettes on the market?
We can learn what happened with alcohol prohibition. When that happened, clearly people were using moonshine and all sorts of denatured alcohol and that was causing more harm. But it was only when alcohol was legalized and regulated that we saw a dramatic drop in the poisonings related to alcohol and alcohol-related harm. Can we not do a similar thing with a very dirty, although legal, delivery device such as cigarettes and have better technology, better development of technology? Currently, where e-cigarettes are, they're in the early stages, so there are many ways one could look at e-cigarettes much like the early motorcar. You know, the horseless carriage. With what we have today, we're moving on to “electric cars”, etc., so we can see how this can progress to really help and be of value to society.
What do we need to do so that we can start that process? We need to be able to study these products better. Currently, our regulatory framework is through Health Canada where I, as a researcher wanting to study this, would need to have hundreds of millions of dollars to even start the research study. Forget about doing the research study. If only to show safety data and exposure data in animals--of course, it's extremely difficult to get animals to smoke--we would have to do this because they are fitting it into a frame of other medicines. Clearly, looking at e-cigarettes as medicine is wrong-headed, because we know what happens with medicines; they don't replace cigarettes. It actually promotes tobacco industry products in some sense, because it doesn't replace them.
Can we create a framework that allows an expedited study of these products so we can actually study them legally with nicotine-containing products, and have an integrated approach so we can study it while we are adding to the evidence base in Canada to make better refinements to the product? We need to look at it clearly because of the huge public health nature of smoking.
To this day, we still have approximately the size of the town of Belleville—that's about 35,000 Canadians—dying every year from tobacco-related illnesses. We know that if smokers stop smoking, within a year their risk of dying is reduced by at least half. So we could see some very immediate benefits if we started having people switching over. You'll hear from my colleagues in the U.K. that 7% of the population there has switched exclusively to electronic cigarettes.
We could have some really huge impacts if we had an investment in studying these products in this way, making sure we had products that met quality assurance standards. They would have to meet certain standards for hygiene, cleanliness, and in what they deliver being consistent from product to product, meeting some sort of standard and having some inspectors going in to make sure these were not being manufactured around children, and to make sure that people are wearing masks and are not coughing into the liquids they're preparing, etc.
Immediately, we need to prohibit e-cigarette vaporizing where smoking is prohibited. We have made so many gains in society and to shift backwards would be a shame, because we would lose all the benefits to health care workers and to workers who work in these places by protecting them from being exposed to these compounds. Clearly, we need to have a policy right away that restricts e-cigarettes from minors. If nothing else, how is it possible that a five-year-old could go into a convenience store and buy an electronic cigarette simply because it says it doesn't contain nicotine? When they do studies on electronic cigarettes right now that claim not to have nicotine, they do find traces of nicotine, because their manufacturing practices are not meeting standards. They get contaminated.
What can we do to restrict sales to minors? How do we prevent the advertising?
If you see the advertising of e-cigarettes in the U.S., it is certainly becoming an undermining effort to helping kids stop or not to start. We certainly need to educate people about the risk, especially youth and pregnant women. Most importantly, we need to have a detailed surveillance and monitoring system that can tell us what people are using and what harms they're coming to.
I'll stop now and take any questions.
Thank you very much for your attention.
