Health Committee on Oct. 28th, 2014

[The Chair, Conservative, Ben Lobb]

Thank you, very much.

Next up we have Dr. Peruga. Please go ahead, sir.

[Dr. Armando Peruga, Program Manager, World Health Organization's Tobacco Free Initiative]

Can you hear me?

[The Chair, Conservative, Ben Lobb]

Yes, we can hear you now. Please carry on.

[Dr. Armando Peruga]

I was saying it is an honour to be able to present testimony to this committee on electronic nicotine delivery systems, ENDS, of which electronic cigarettes are the better known type. My testimony is presented on behalf of the World Health Organization, based on its report on ENDS, which was prepared in response to the request made by the Conference of the Parties of the WHO Framework Convention on Tobacco Control. This report was presented at the sixth session of the COP, Conference of the Parties, which just took place two weeks ago. A copy of this report in English and French has been provided to the committee. My testimony will refer also to the decision adopted by the sixth session of the COP on ENDS, also provided to the committee.

ENDS are the subject of a health debate among bona fide tobacco-control advocates. Whereas some experts welcome ENDS as a pathway to the reduction of tobacco smoking, others characterize them as products that could undermine efforts to denormalize tobacco use. ENDS, therefore, represent an evolving frontier, filled with promise and threat for tobacco control. ENDS deliver an aerosol by heating a solution that users inhale. The main constituents of the solution by volume, in addition to nicotine when nicotine is present, are propylene glycol, with or without glycerol and flavouring agents.

The global ENDS market is presently formed by about 500 brands, which use liquids presented in close to 8,000 flavours. Transnational companies have entered the ENDS market and are increasingly dominating it. Questions related to the use of ENDS as reflected in the WHO report have been articulated in three groups include whether ENDS pose health risks to users and non-users, whether they are efficacious in helping smokers to quit smoking and ultimately nicotine dependence, and whether they interfere with existing tobacco-control efforts and implementation of the WHO FCTC.

When talking about the health risk of ENDS it is important to know that the battery voltage, unit circuitry differences, and the type of solvent used in the liquid result in considerable variability of the level of nicotine and other constituents they deliver, including the formation of toxicants in the emissions.

In the area of risks to health I would like to say three things.

In terms of risks from nicotine inhalation, a key concern with nicotine is its capacity to affect the brain development of foetuses, children, and adolescents; hence, our recommendation to regulate ENDS in a way that avoids initiation of ENDS by these groups.

In terms of health risks resulting from chronic inhalation of toxicants from ENDS, conclusive evidence about the association of ENDS use with specific diseases will not be available for years or even decades, given the relatively recent entry of ENDS into the market and the lengthy lag time for onset of some diseases of interest such as cancer. However, evidence based on the assessment of the chemical compounds in the liquids used and in aerosol produced by ENDS indicate that average ENDS use produces lower exposures to toxicants than combustible tobacco products, although some ENDS can produce levels of some carcinogens that are similar to that produced by cigarettes. Hence our recommendation is to regulate ENDS in a way that minimizes risks for users and avoids the initiation of ENDS use by non-smokers.

In terms of risks to bystanders, they are exposed to the aerosol exhaled by ENDS users, which increases the background level of some toxicants, nicotine as well as fine and ultrafine particles in the air, although at levels lower than that of conventional cigarette emissions. It is not clear if these lower levels in exhaled aerosol translate into lower exposure, as demonstrated in the case of nicotine. Despite having lower levels of nicotine than in second-hand smoke, the exhaled ENDS aerosol results in similar uptake as shown by similar serum cotinine levels. It is unknown if the increased exposure to toxicants and particles in exhaled aerosol will lead to an increased risk of disease and death among bystanders as does the exposure to tobacco smoke.

However, epidemiological evidence from environmental studies shows adverse effects of particulate matter from any source following both short-term and long-term exposures. The low end of the range of concentrations at which adverse health effects have been demonstrated is not greatly above the background concentration, which means that there is no threshold for harm and that public health measures should aim at achieving the lowest concentrations possible. Hence, our recommendation is to protect non-users in indoor public places.

In terms of ENDS as an aid to quit smoking, although anecdotal reports indicate that an undetermined proportion of ENDS users have quit smoking using these products, the evidence for the effectiveness of ENDS as a method for quitting tobacco smoking is limited and does not allow us to reach conclusions at this point. Hence, our recommendation is to impede unproven health claims about ENDS.

From the point of view of the impact of ENDS on existing tobacco-control effort there are several concerns.

One is that ENDS could be a gateway to nicotine dependence and smoking for youth. The likelihood and significance of this effect occurring will be the result of a complex interplay of individual, market, and regulatory factors and is very difficult to predict. They can only be assessed with empirical data which at present are limited. These data show that young, never smoker users of ENDS is about 1% in the few countries which have data. In some countries this figure does not seem to grow while in at least one country, Poland, ever use of ENDS among never smokers between 15-19 years-old has gone up from 1.6% to 7.1% in three years and current use has gone up from 0.6% to 2% coupled with a significant increase of smoking in this age group.

Another concern is the aggressive marketing of ENDS by some tobacco companies to be used in smoke-free environments as a way to break the enforcement of smoke-free policies.

A third and final concern is the role of the tobacco industry that is at the same time marketing conventional and electronic cigarettes in order to dominate the ENDS market and to preserve the status quo in favour of cigarettes for as long as possible. The industry’s historic interest in smokeless tobacco products outside some Nordic countries, for which similar benefits to ENDS were made, was because they could be used, as declared in their own documents, in smoke-free environments and could be promoted to young, non-tobacco users to create new forms of tobacco use. All of this is while they were simultaneously pretending to be part of the solution to the smoking epidemic because they present ENDS as the solution to the epidemic that they themselves have created.

After consideration of the report and extensive deliberations of the COP of the WHO FCTC during the week of October 13, 2014, the 179 parties to the WHO FCTC decided unanimously to welcome the WHO report, invite parties to take careful note of it, and request WHO for an update to be presented in two years. They also decided to invite parties to consider taking measures to at least achieve the following objectives in accordance with national law: first, prevent the initiation of ENDS by non-smokers and youth with special attention to vulnerable groups; second, minimize as far as possible potential health risks to ENDS users and to protect non-users from exposure to their emissions; third, prevent unproven health claims from being made about ENDS; and fourth, protect tobacco control activities from all commercial and other vested interests related to ENDS including the interests of the tobacco industry. It was also going to invite parties to consider prohibiting or regulating ENDS, including as tobacco products, medicinal products, consumer products, or any other categories, as appropriate, taking into account a high level of protection for human health. Finally, they urged parties to consider banning or restricting advertising, promotion, and sponsorship of ENDS, as well as to comprehensively monitor the use of ENDS.

Thank you for your attention.

I'll be glad to respond to any questions you may have about issues pertaining to...[Inaudible--Editor].

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much, gentlemen, for your presentation.

First up, for seven minutes, is Mr. Kellway.

[Matthew Kellway, NDP, Beaches—East York, ON]

Thank you very much, Mr. Chair.

And thank you, gentlemen, for joining us today.

You provided us with a lot of information in a very brief time.

If I could start with a bit of clarification, Dr. Peruga, your comments are with respect to electronic cigarettes that contain nicotine, I presume. Is that the case? Is that what you were dealing with entirely in your comments?

[Dr. Armando Peruga]

No, sir. They are with respect to those that contain nicotine as well as those that don't contain nicotine.

[Matthew Kellway, NDP, Beaches—East York, ON]

Okay. Are you treating the electronic cigarettes with and without nicotine under the same approach?

I'm sorry. I didn't find or hear or detect in your presentation distinctions between regulation of one with nicotine and one without. Is there a clear distinction between your suggested treatment of these things?

[Dr. Armando Peruga]

Only with respect to the fact that electronic cigarettes, when they contain nicotine.... You could regulate that part, but the rest is exactly the same with those that contain nicotine and those that don't.

[Matthew Kellway, NDP, Beaches—East York, ON]

Okay.

Your comments, if I understand them, about whether electronic cigarettes are a substitute for combustible cigarettes, suggest that the evidence is unclear whether this is the case or not.

[Dr. Armando Peruga]

Yes. The two points that relate to that is whether they are less or equally toxic. We think they are less toxic—in some cases extremely less toxic and in some cases not so much. There is some variety across brands and within brands.

Secondly, in relation to whether in addition they can be an effective substitute to switch from smoking cigarettes or other combustible products to electronic cigarettes, we have concluded that the evidence right now doesn't allow us to reach a definite conclusion on that.

[Matthew Kellway, NDP, Beaches—East York, ON]

Thank you.

Dr. Britton, with your rolling survey, you threw a lot of statistics out there. I wonder if you could go over them for me, please, and tell me whether you have found in that rolling survey whether the electronic cigarette is acting as a substitute for the combustible one.

[Dr. John Britton]

Thank you.

It's not my rolling survey. It's carried out by Professor Robert West at the University College London. It's available online if you search under Smoking in England and the latest electronic cigarettes statistics. What he shows is that over the last two or three years there has been a progressive increase in use by smokers, both occasional and regular use. Largely, the use of electronic cigarettes has been cannibalizing the market in over-the-counter nicotine replacement therapy products.

What we see is a great deal more smokers using a nicotine product, if you lump NRT and electronic cigarettes together, and as a consequence, increased quit rates and increased numbers of smokers trying to quit.

Does that answer your question?

[Matthew Kellway, NDP, Beaches—East York, ON]

Yes.

How much is that increase? Can you quantify it for me?

[Dr. John Britton]

Well that's hard to say because it's a rolling survey of a couple thousand people. There is a separate survey by Action on Smoking and Health, published in the middle of this year, which came up with a similar figure that about two million, or one in five, smokers are using electronic cigarettes occasionally, and of those about 700,000, or just over one third, were using electronic cigarettes exclusively as a substitute for cigarettes. So they've given up smoking.

Our smoking statistics figures for 2013—some preliminary figures were released last week—show a drop in prevalence from 19.9 to 18.6, I think, which is the biggest year-on-year fall in prevalence over the last couple of decades.

[Matthew Kellway, NDP, Beaches—East York, ON]

Dr. Britton, if I were to characterize your comments about the other risks that attend the e-cigarettes, including other substances that come out of these things in the vapour as somewhat more casual—I think your comment was that we can manage these risks—can you explain that? Is it the harm reduction approach that you take that suggests that we have a bigger issue to deal with the combustible cigarettes and, therefore, let's get on with figuring this out and set those longer term risks aside?

[Dr. John Britton]

I wouldn't completely set them aside. I think one area that I would disagree with my colleague on here is that the risks of electronic cigarettes are unknown and will vary from product to product. Poor quality products burn or heat the nicotine less effectively and less thoroughly and produce more toxins than others, but with a good quality product the level of risk, although unknown, is in an order or two orders of magnitude lower than that of inhaling cigarette smoke. So whilst there is a risk there, that risk is trivial in comparison to the risk of continued smoking. The challenge is to try to minimize that risk as much as possible. As has been argued, it will be decades before we know what the impact of that is. But to minimize that risk by making the emissions as clean as is reasonable....

I think the risk is very low. So it's not that we can ignore it but I think we just have to keep it in perspective.

[Matthew Kellway, NDP, Beaches—East York, ON]

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Next up for seven minutes is Mr. Wilks.

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

Thank you very much to both parties appearing today.

Firstly, Professor Britton, regarding a commissioned report to Public Health England, which you were involved with in May of this year, I wonder if I could just ask you a couple of questions. Part of that report said:

Electronic cigarettes, and other nicotine devices, therefore offer vast potential health benefits, but maximising those benefits while minimising harms and risks to society requires appropriate regulation, careful monitoring, and risk management. However the opportunity to harness this potential into public health policy, complementing existing comprehensive tobacco control policies, should not be missed.

What potential health benefits do you see in e-cigarettes as they currently exist? What changes to the current regulatory systems, if any, would be needed to maximize those benefits?

[Dr. John Britton]

Sorry, the first question was what?

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

What potential health benefits do you see in e-cigarettes as they currently exist?

[Dr. John Britton]

The current benefits are massive because lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease are the three biggest killers from cigarette smoking. Those conditions are, so far as any of us knows, caused almost entirely by constituents of tobacco smoke other than nicotine. It's not to say that nicotine is completely safe, but it's not the cause of the harm from tobacco smoking. So the benefits of electronic cigarettes are that if the entire population of smokers in Britain switched to electronic cigarettes from smoking tobacco, we would see the incidence of those conditions drop dramatically—heart disease in the very near future and COPD and lung cancer in the more distant future.

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

One of the questions I would have—and I'll relate to one of my family members who's a smoker, my lovely son, who has taken up e-cigarettes—is this. He will smoke e-cigarettes at home. He's part of our military family so when he goes on an exercise and he can't plug the e-cigarette in to recharge it, he goes and buys a pack of cigarettes because he can't still do without the nicotine. So my question to both you, Dr. Britton and Dr. Peruga, is this.

Aren't we just really substituting one for another? It seems to me from firsthand knowledge that I can see that we may be just substituting one for another. I understand the benefits. I can see potential benefits there. But how do we stop those people, for lack of a better word, from being dually addicted to two different substances? How do you stop that?

I'll start with you, Dr. Peruga, and then go to Dr. Britton.

[Dr. Armando Peruga]

You pose a very interesting question, which is at the heart of the matter. It's that the potential benefit would be maximized when the great majority of smokers substitute entirely for electronic cigarettes. If that happens, the potential will become important.

There's a problem we see, at least in the research that has been published in terms of clinical trials, which are very limited in terms of how efficacious they are.... This doesn't amount to a body of evidence, but some of them show that they have a low efficacy, which leads basically to dual use in most of the smokers. It's difficult to know whether that's good or bad, because obviously you can make the argument that, well, if you smoke two cigarettes less a day, that's an advantage. The problem is a sore one and it's difficult to respond to, but there are two other questions you have to pose.

One, we know that the maximum benefit from quitting smoking is not necessarily in reducing the amount of tobacco. The risk reduces primarily from the duration of the use and not the amount used, so that's a concern. I'm not saying that this is the only factor to consider, but the fact that people will continue using tobacco will mean that the potential benefit of electronic cigarettes is greatly diminished.

The other thing is this: what does it mean to have dual use? I think we can agree that the ultimate goal is obviously to switch entirely from tobacco to ENDS and, if possible, to abandon the addiction to nicotine. Whether dual use is able to achieve that in the long term or offer possibilities to go back to the use of tobacco is something that is uncertain.

I'm sorry that at this point I have more questions than answers, but it is indeed a very important issue.