Health Committee on Oct. 30th, 2014

[Manuel Arango]

I'm not aware of any.

[The Chair, Conservative, Ben Lobb]

Ms. Fry, you'll have the final round for this segment. Go ahead, please.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair.

You both make a lot of sense, and I think we've heard enough people saying the same thing, that this could be a pathway to helping people to quit, reducing second-hand smoke, and all of that. It's therefore safer than others.

I know that I agree that there should be regulations. But let us imagine you regulated it, you put age limits on it, and you did all of those kinds of things. How would you go about getting a study that would find out if people are dual using? That would depend on an honour system. People would have to say, “I'm dual using”.

How would you find out whether young people, when they get to the age of starting to smoke and they use e-cigarettes, would have normally started to use cigarettes or would they have just gone on to e-cigarettes? Would it be bringing in more people because they think it's safer? Would more people begin to use cigarettes?

All of that is pretty difficult to analyze. How would you see us doing that? I think that's going to be key, isn't it? That would be a difficult research project.

[Manuel Arango]

Well, it is possible. I would just make mention of one fact related to testing. You're right that with self reports, if you just ask someone through a survey whether they're smoking e-cigarettes or not, it's not going to be as reliable as other methods. If you interview a person face to face, you'll get better results.

[Hedy Fry, Liberal, Vancouver Centre, BC]

So it would have to be a personal interview.

[Manuel Arango]

Yes, and also for example with cigarettes, there is testing that can be done to determine if someone actually has had nicotine and has been smoking.

Something could be developed with e-cigarettes as well, in terms of research that could help the research to be more accurate.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Given that the patch and the gum haven't really given you the right outcomes that we're looking for, how would you see regulating the potency of nicotine or the amount of nicotine in an e-cigarette? What would be your ideal dose? Do you have any idea how you would do that?

[Rob Cunningham]

There's not regulatory experience yet. The European Union is starting in this direction. I can imagine how there could be maximum levels, but this is a matter of ongoing study and consideration. As regulators and governments pursue this, we'll have a better idea as to what the optimal regulation is in that area.

[Manuel Arango]

I'll add a point. Obviously we don't have all the answers now, but the situation is of such concern that we think regulation should go ahead in an expedited fashion and then, as more research comes in, those regulations could be tweaked and adjusted as necessary, but we think we have enough evidence right now to warrant immediate action.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I know we heard from the United Kingdom yesterday. There was a strong emphasis by the public health officer who presented to us that they've decided that it's a very important tool to use in helping people to quit. So they've gone ahead and decided to let it be used. At the same time they're trying to do some of that research, as you say.

In Poland some research showed that people who never smoked before are beginning to use e-cigarettes. It's the only one of the studies that showed this was happening. I think the other ones didn't show that. I think it would be really important to look at that issue, because if you're going to decide you want to use it to help people quit, that's one good thing. But if it's going to be encouraging more people to use nicotine—not that nicotine in itself is terribly harmful, but to be using some sort of vapour with who knows what toxic things are going to come out, which only time can tell—it would prove then that you've created a new type of method of getting hooked on nicotine and on whatever the side-effects are of that.

How then would you go about getting rid of e-cigarettes if they prove to be that way, having allowed their use to become normal? It would be difficult to shut that door once you've opened it.

[Rob Cunningham]

I think the fundamental point of the importance of marketplace surveillance is really important, so the successor to the “Canadian Tobacco Use Monitoring Survey”. Governments and health organizations use that very good data. How are things changing in the youth smoking survey? Are kids picking this up? Are there people who have never smoked? Are there former smokers who have relapsed? Is there no change? What are the patterns? We need fundamental information to inform policy-making and to make adjustments.

[The Chair, Conservative, Ben Lobb]

Okay.

Thank you very much.

This has been a great panel this morning; you're welcome to stick around till the committee meeting is over. We're going to suspend for a couple of minutes. We'll be right back at about 12:25. That will allow our guests to come, and we'll get everybody settled.

[The Chair, Conservative, Ben Lobb]

Welcome back.

We're into the second round. For our second panel for today's meeting, we have the Canadian Lung Association and the Canadian Public Health Association.

We'll start with Margaret. You're the executive director of the Manitoba Lung Association.

[Margaret Bernhardt-Lowdon, Executive Director, Manitoba Lung Association, Canadian Lung Association]

That's right.

[The Chair, Conservative, Ben Lobb]

You have 10 minutes. Please go ahead.

[Margaret Bernhardt-Lowdon]

As you mentioned, I am the executive director of the Manitoba Lung Association, but I'm here today to represent the Canadian Lung Association.

First of all, I would like to thank you for holding this hearing, because we really feel that the use of e-cigarettes is a serious health issue that warrants the attention of Parliament.

The mission of the Canadian Lung Association is to promote and improve lung health, and we've been doing that for over 100 years, 106 in Manitoba in particular. We really are concerned about this and think it's a really important issue. We're a non-profit health charity, and this is really all we focus on, because we believe that if you can't breathe, nothing else matters.

Because you know all about health, I'm sure you're aware of the inherent risks of tobacco use and the devastation that smoking can cause for the smoker, their loved ones, and the health-care system. As you know, tobacco use remains the leading cause of preventable death in Canada, and it's also the main cause of lung disease. More than 100 Canadians will die today, tomorrow, and every day from diseases that are caused by smoking. We're talking about diseases like COPD and lung cancer.

I wish that we as an organization could recommend the use of these cigarettes as a safe alternative to smoking. I also wish that I could sit here today and recommend them as a safe smoking cessation aid. However, we have a role in Canada, and that role is to protect the lung health of Canadians. So we feel we should ensure that e-cigarettes do not cause any harm to users or to the people in their vicinity when they're using the product. We also feel, like the Cancer Society and the Heart and Stroke Foundation, that their use will undermine efforts to eliminate smoking in Canada.

Therefore, I'm here to talk to you about our concerns and our policy recommendations for e-cigarettes, both those with and without nicotine. In particular, our concerns focus on safety, current regulations and enforcement, uptake by youth, and the potential renormalization of smoking.

In terms of their safety, we don't really know if e-cigarettes are safe. There's been very limited testing of the toxicity of the product and and its emissions. In addition, because there's no regulation, the ingredients vary from product to product, as do the side-effects. There isn't enough information on the long-term health impacts of inhaling the vapour that e-cigarettes create or the effect of second-hand exposure. This is of particular concern to us, especially because some of the early studies coming out are showing that e-cigarettes actually can irritate the airways of some people that use them. It's also showing that they can have bad effects on people who have asthma. We feel strongly that Canadians really need to know about these risks, if they're going to be using e-cigarettes.

In terms of regulations and enforcement, we all know that e-cigarettes with nicotine are not allowed to be sold, but I can tell you that they are being sold in Winnipeg, where I work. We had a report the other day in one of our local newspapers saying that the reporter had gone into the shop, sat down with the owner, told him about what type of addiction they had to cigarettes, and they were given a specific e-cigarette to use with a specific amount of nicotine.

[An hon. member]

Prescribing it?

[Margaret Bernhardt-Lowdon]

Prescribing, yes.

We know it's happening, but it's not really being fully enforced. Many e-cigarettes are still being sold on shelves labelled as nicotine-free, and studies are showing they have nicotine in them.

We think that Canadians should be able to fully understand what they're inhaling when they use these products. Safety requirements and quality assurances should be put into place. These would include things like listing the ingredients, letting people know if the ingredients are harmful, and giving information on potential health risks to clients, patients, or anyone who uses them.

One of other concerns, as has been said before, is the uptake by youth. I'm one of those people who started working on this in the trenches in the nineties; I'm one of 10,000 or more other people who has done this work.

One of our concerns, as you said, is that there may be an alternative to smoking to help people quit, but studies are starting to show that kids who have never smoked are using them and that's how they're starting. Our biggest concern is that they will go on. If they use them for the first time and they continue to use them, they'll have a life that circulates around the e-cigarette, just as it would with a cigarette. We don't want these kids to have a lifetime addiction to nicotine.

We also know that youth are being targeted by e-cigarette marketing and branding campaigns. As has been said before, these products come in a variety of candy flavours, like juicy peach, root beer, and cherry crush. When these flavoured e-cigarettes are displayed without restriction on cash counters and retail outlets, kids might be tempted to try the product. E-cigarettes should not be allowed to be sold to minors. There should be regulation in Canada on flavours, making e-cigarettes much less appealing to youth.

We're also concerned about potential normalization. The use of the e-cigarettes in places where smoking is banned, we know will contribute to the social visibility of smoking in public places. We worry that e-cigarettes used in public places and indoor environments will increase the attractiveness of smoking behaviour. This is something that will undermine years of denormalization work. E-cigarettes should be banned in places where smoking is banned, and this should include workplaces that are federally regulated.

Now, when it comes to using them as a smoking cessation aid, we find that people are confused about e-cigarettes. A lot of people think that they are safe. Our organization is striving for a smoke-free country. We're always very interested in looking at methods to help people quit smoking. We know that about 85% of smokers in Canada who smoke want to quit, and we want to help them do that. lt's imperative that cessation aids go through rigorous testing to ensure that they're safe and effective. This hasn't happened for e-cigarettes; therefore, we cannot in all good conscience state that e-cigarettes are entirely safe to use.

Canadians are using e-cigarettes without knowing their contents or potential harmful effects. We encourage Canadians to use cessation aids that have been approved by Health Canada. However, many Canadians mistakenly think that e-cigarettes pose no safety risks. This may be because current regulations are not enforced. lt may also be because consumers can buy e-cigarettes in pharmacies right next to the smoking cessation aids approved by Health Canada.

The Health Canada website warns Canadians not to use e-cigarettes to try to quit smoking. We would like to have these messages disseminated widely.

We are concerned that we may lose ground in reducing smoking in Canada, and we are fearful of a future where youth become addicted to nicotine by using e-cigarettes. We firmly believe that action must be taken on this issue.

I want to thank you for your time and interest today, and I would be pleased to answer any questions that you may have. l look forward to your thoughts and comments.

Thank you.

[The Chair, Conservative, Ben Lobb]

Okay.

Next up is the Canadian Public Health Association, and Mr. Culbert.

Go ahead, sir.

[Ian Culbert, Excutive Director, Canadian Public Health Association]

Thank you, Mr. Chair, and committee members.

I appreciate the invitation and the opportunity to present to you today. I'm going to present my notes in shorthand, because I don't want to bore you with repetition

Obviously, there's a debate going on. The horse has left the barn: e-cigarettes are a part of our culture today, and to pretend otherwise is foolish and will cost us in the long run.

I will frame my remarks using your study questions and begin with the potential risks, benefits, and challenges. Certainly the public health challenge that is posed by e-cigarettes is how to balance the harm reduction approach with the precautionary principle. Our preferred option is that no one inhales anything into their lungs other than clean, fresh air, a phrase that I think I stole that from the Lung Association. I'll give credit where it's due.

A harm reduction approach recognizes that human beings sometimes behave in ways that are detrimental to their own health and well-being. That's unfortunate, but it's a fact of life. Accepting this, public health authorities establish policies and programs that aim to reduce the harms associated with these behaviours. lt is a principle that supports choosing the lesser of two evils as a means of reducing the societal and personal costs of our own poor choices. On the other hand, we have the precautionary principle that states that complete evidence of a potential risk isn't required before taking action to mitigate the effects of that potential risk. This is also a foundational principle of many public health policies and programs; the two go hand in hand. How do you balance them in this situation?

Clearly, e-cigarettes appear to have potential as a harm reduction tool, but they also pose potential risks for which we don't have complete evidence at this point. As has been stated before, studies are revealing that e-cigarettes seem to contain fewer toxins than traditional cigarettes, but there are serious quality control concerns with what is actually in the e-cigarettes. As has been noted, no e-cigarette product has been systematically evaluated and approved as a smoking cessation device by any governmental agency either here in Canada or abroad. Having said that, I take from an earlier comment that you've heard from the U.K. yesterday, and certainly their Medicines and Healthcare Products Regulatory Agency is currently in the process of reviewing some of these products. We should keep a close watch on their results. I would urge one bit of caution around the remarks coming out of the U.K. It's a very different smoking cessation environment. They're still debating smoking in public spaces there, meaning smoking in pubs, which is still happening. So it's a different kind of landscape. I'm not saying I disagree with their approach, but it is a different cultural environment when it comes to smoking and that has to be taken into consideration.

As has been discussed, e-cigarettes have potential risks, including the direct health risks to users and non-users, as well as their potential as a gateway to traditional smoking. There's just not enough research on these topics, but what we do know, as mentioned before, is that there are wide variations in the nature of toxicity and in the contents of the emissions of e-cigarettes. We know that the short-term effects of e-cigarette use include eye and respiratory irritation caused by exposure to propylene glycol. In terms of the evidence regarding e-cigarette use and more serious diseases, such as cancer, we are decades away from knowing about that, as it takes that long for those diseases to show up.

ln addition to the concerns about the direct health impacts, there's an extensive and really heated debate about whether e-cigarettes will prove to have a positive or negative impact on population health and tobacco control. Are they a gateway? Do we know? We don't know yet. Some studies show possibly. Some are saying, yes, non-smokers are interested and maybe they'll try it, but it's really smokers and former smokers who have the greatest interest in them. We just don't have enough information right now.

Next, I'll speak to the question about the manner in which different jurisdictions have chosen to regulate e-cigarettes. Front-line public health organizations across this country have fought the tobacco wars for decades and have achieved great success in reducing smoking rates through a combination of education, cessation support, policy, and legislation. They are not willing to see these accomplishments destroyed by the re-establishment of smoking as an acceptable behaviour. As you've seen recently, in Toronto and Vancouver, their municipal governments have enacted bans on the public use of e-cigarettes that match the current bans on smoking in public and it's likely going to be replicated in other Canadian jurisdictions.

lnternationally, results from the 2014 World Health Organization survey indicate that 27% of countries have regulated e-cigarettes as consumer products, 6% as therapeutic products, and 10% as tobacco products. However, 51% of countries have no regulatory approach in place at all. The survey also indicated that 39 countries have advertising bans. E-cigarette use in public places is banned by 30 countries. Pre-market review is required by 19 countries. Vendor licences are required in only 9 countries, but 29 countries have already banned the sale of e-cigarettes to minors. Those are some great examples of what other countries are doing right now.

As has been discussed, nicotine is a controlled substance and is addictive. As such, the federal government's current prohibition on nicotine-containing e-cigarettes is appropriate. This prohibition, however, is ineffective and enforcement efforts have been minimal.

Nicotine-containing e-cigarettes are readily available in the United States through the Internet, and probably within walking distance of this committee room, so any policies on managing these products in Canada must presume their general availability. It's a porous border.

What we know is that prohibition doesn't work. It doesn't matter what the substance is. If somebody wants to get their hands on something, they're going to get their hands on it. And if there's money to be made in giving it to those people, others will find a way to make it happen. What we are dealing with in Canada is effectively an unregulated environment and steps do need to be taken to address the situation.

I'm going to echo some of the recommendations that have already been heard, but I think they bear repeating. Canada currently prohibits anyone from making health claims about e-cigarettes until evidence supporting such claims is documented and the government grants regulatory approval for the sale of the product. To date, no e-cigarette manufacturer has gone through this process and, in all honesty, they have no good reason to do so. The status quo suits their business model as long as interdiction and enforcement remain marginal at best. Why would you jump through the hoops and add to the cost of your product when it's a porous market? They can sell them. Estimates range that it could be upwards to a $4-million market in Canada now, and it's only growing.

To the best of my knowledge the Government of Canada has no regulatory instrument at its disposal to compel manufacturers to submit their products for scientific testing. E-cigarettes are a new technology and possibly a new regulatory tool will be required. Until that time, and at the very least, all e-cigarettes should be reviewed for safety under the Canada Consumer Product Safety Act.

As previous speakers have mentioned, we are encouraging the federal government to ban the use of e-cigarettes in all public places under its jurisdiction. We are also calling for the government to place a ban on the advertising, promotion, and sponsorship of e-cigarettes, similar to those in place for tobacco products. The Government of Canada should also regulate e-cigarette solutions with fruit or candy flavours, and the manufacturers and importers should be required to disclose to governmental authorities information about the content and emissions of their products.

Finally, funding is required for additional research into the health effects of e-cigarettes, their efficacy as a smoking cessation device, the epidemiology and toxicology of e-cigarette use, and their psycho-social impact on existing tobacco-control efforts.

Smoking tobacco kills and millions of current smokers will die prematurely from their smoking unless they quit. We know that. We also know this burden falls predominantly on the most disadvantaged in Canadian society. It is the poor who smoke the most. Let's not forget that.

Traditional cigarette smoking remains the most significant and preventable cause of chronic disease today, but given recent cuts to the federal tobacco strategy, it is highly unlikely that that will change in the future. If we don't keep up the war on tobacco, we're always going to be slipping.

The emergence of electronic cigarettes provides a radical alternative to tobacco. However, in order to maximize the potential benefits associated with e-cigarettes, we simultaneously need to minimize the potential harms and risks to society. To do so will require appropriate regulation, careful monitoring, and risk management. What was needed a decade ago was an early and coherent response by the federal government that included a well-funded research program that coordinated with programming and policy and produced useful results within a 3-year to 5-year timeframe. We're long past an early response.

I do urge the government not to lose out on the opportunity for a coherent response now. Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mr. Donnelly, go ahead, sir.

[Fin Donnelly, NDP, New Westminster—Coquitlam, BC]

Thanks very much, Mr. Chair. I want to thank both of our presenters for providing testimony to the committee today.

I have a few questions. First of all, can minors purchase e-cigarettes right now?

[Margaret Bernhardt-Lowdon]

Yes, and they do.

[Ian Culbert]

Yes.

[Fin Donnelly, NDP, New Westminster—Coquitlam, BC]

Do you both agree that further regulation is needed with electronic cigarettes?