Health Committee on Oct. 30th, 2014

[The Chair, Conservative, Ben Lobb]

Good morning, ladies and gentlemen.

We're in our third meeting studying e-cigarettes. We have two panels today. Seeing how we had votes this morning, we're going to compress the panels. We want to get right at it as best we can.

First up we have the Canadian Cancer Society and the Heart and Stroke Foundation of Canada. We'll start with these two groups, and with Mr. Cunningham.

Welcome. You have your prepared comments. For 10 minutes or less, if you can, sir.

[Rob Cunningham, Senior Policy Analyst, Canadian Cancer Society]

Mr. Chair and committee members, on behalf of the Canadian Cancer Society, I would like to thank you for the opportunity to testify today.

Along with our prepared testimony that's been circulated you should also have a short reference binder.

Electronic cigarettes are a new product category that has seen rapid sales growth in Canada in just a few years. The types of electronic cigarettes are evolving in terms of their product design. Some products are disposable, some are refillable, and some are rechargeable.

A government response at federal and provincial levels is necessary. We have policy recommendations for both government levels. These recommended policies should be implemented for all e-cigarettes, whether they contain nicotine or not, and whether or not Health Canada has approved e-cigarettes with nicotine for sale in Canada. These policies should also apply to e-cigarette components such as liquid.

Health Canada has to date approved only the following five nicotine replacement products for smoking cessation: gum, patch, lozenge, inhaler, and mouth spray. Health Canada has not yet approved e-cigarettes as a cessation product.

Are e-cigarettes less harmful than cigarettes? Yes, because the products contain no tobacco, nor tobacco smoke. At the same time, the long-term health effects are not yet known, and effects may vary depending on a particular e-cigarette.

As Health Canada indicated last week, there is potential for some e-cigarettes to be an effective substitute and cessation product for some smokers. Research is evolving in this area. At the same time, research is needed to curb certain risks. Regulations are needed to prevent young people from using e-cigarettes and to help prevent e-cigarettes from undermining tobacco control efforts to reduce smoking.

A consideration is that tobacco companies are now selling e-cigarettes internationally. Tobacco companies have a motivation to keep smokers smoking, not to get smokers to quit altogether. A significant proportion of smokers are engaging in dual use, using both regular cigarettes and e-cigarettes, which has an important effect on health risks.

In Canada there is significant youth use of e-cigarettes, which is notable given that availability has only been recent in Canada. Clearly this is a concern. Research commissioned by the Canadian Cancer Society in Quebec—and in tab 1 there's a news release on that—found that for the 2012-13 school year, 9% of students in Grade 6 had tried e-cigarettes. And among Grade 11 students, 41% had tried e-cigarettes.

First, in terms of federal legislation, there needs to be a ban on e-cigarettes sales to minors. This is obvious. Right now e-cigarettes could be legally sold to an eight-year-old. But banning e-cigarette sales to minors by itself is insufficient to protect youth. We know from long-standing experience with tobacco legislation that sales to minors laws are notoriously difficult to enforce. The most recent Health Canada evaluation found that fully one in six stores sold tobacco illegally to youth. Kids find and know the stores that are willing to sell illegally.

Second, use of e-cigarettes should be banned in workplaces and public places under federal jurisdiction where smoking is banned. While use in workplaces and public places is primarily a provincial issue, about 10% of Canadian workers are federally regulated, including banks, transportation, broadcasting and communications, the federal public service, and crown corporations such as Canada Post. Airplanes, and most ships, trains, and buses are federally regulated. An amendment to the federal Non-smokers' Health Act is necessary, as well as to some other federal regulations.

Third, there need to be strong federal restrictions on advertising and promotion, though some product information could be allowed at point of sale. Sales of e-cigarettes in Canada have grown dramatically, even in the relevant absence of advertising. At present in Canada there is little advertising for e-cigarettes except at point of sale and on websites. In the U.S., however, there is wide open advertising. There is lifestyle advertising using the same themes that we previously saw for tobacco advertising, such as sexual attractiveness, sophistication, and social acceptability.

I have with me the 2014 Sports Illustrated swimsuit issue, which is widely read by teenage boys. With the committee's consent, I have an enlarged version of one advertisement for e-cigarettes, which reads: "Slim. Charged. Ready to go. Available nationwide! Visit us at blucigs.com/store-locator". We cannot say that the makers are not targeting teenagers.

This ad and other ads are found in the binder that you have from the United States. The first ad in tab 3 has the headline: “Why Quit? Switch to blu”. Here, there's a direct appeal marketing e-cigarettes as an alternative to quitting, as opposed to an alternative to smoking.

There is lots of U.S. advertising that encourages use of e-cigarettes in places where smoking is banned. This is a problem, because it promotes e-cigarettes not as a substitute for smoking, but as a substitute for not smoking. This undermines the benefits of smoke-free places, which is a highly effective strategy to motivate smokers to quit. Claims that advertising for e-cigarettes will only target adult smokers should not be accepted. Just look at U.S. advertising. The tobacco industry made the same claims in Canada, yet it is clear from internal documents that tobacco companies advertise to under-age youth and to discourage smokers from quitting.

Four, there needs to be strong restrictions on flavours. One store in Ottawa sells flavours such as groovy grape, peppermint, watermelon, and pina colada. Other flavours include blueberry cotton candy, caramel apple, skittles, and orange creamsickle, as indicated by website printout in tab 4. There are hundreds of flavours. For nicotine replacement products, such as nicotine gum and nicotine lozenge, Health Canada has approved a limited number of flavours such as mint and orange, thus the possibility of some approved flavours should be left open, but the principle should be that only flavours approved by Health Canada should be allowed.

Five, Health Canada has a responsibility for packaging and labelling just as it does for nicotine replacement products. Also, Health Canada should regulate e-cigarette products themselves regarding harmful ingredients and vapour emissions. Regulations should require that e-cigarettes be visually distinct in appearance from regular cigarettes to assist with enforcement, and to respond to concerns about re-normalization. The marketplace, in any event, is moving in this direction. Health Canada should also assert regulatory control over e-cigarettes without nicotine, in part because these products can often be filled with liquid containing nicotine, and there's already been reference to other substances that could be included. Health Canada should require public disclosure of ingredients and should have other detailed reporting requirements, such as sales data, marketing practices, and product information.

At the provincial level, governments should act and indeed, several provinces are bringing legislation forward. First, provinces should ban sales to minors, which is primarily a provincial responsibility in terms of enforcement.

Second, provinces should ban use of e-cigarettes in workplaces and public places where smoking is banned, including outdoor areas such as patios and school grounds. The main reason for this is to protect the effectiveness of smoke free places as a motivator for people to quit smoking. The further issue is second-hand vapour that contains nicotine and other substances—and it's not just water vapour. The long-term effects of exposure to second-hand vapour are not yet known, though it would be less harmful than second hand cigarette smoke.

Third, provinces should significantly limit locations of sale, control, and supply. E-cigarettes should not be in every convenience store and gas station. For tobacco, the number of retail outlets is excessive and tobacco control efforts are trying to reduce that.

Fourth, provinces should have regulatory authority over the product, including flavours, and over advertising and promotion. Ideally, these matters would be dealt with federally, but provinces could act in the absence of effective federal regulation.

Until there is provincial legislation, municipalities should adopt by-laws to prohibit use of e-cigarettes in workplaces and public places where smoking is banned. Roughly 10 municipalities in Canada to date have taken action on this and many more can be expected to do so. We will submit an updated list to the committee next week.

In the U.S., where e-cigarettes have had earlier growth than in Canada, three states and more than 200 municipalities have taken action, including New York City, Boston, Chicago, and Los Angles. You have full listings in tab 5 of the binder.

In conclusion, swift government action is needed. Governments need to move forward with an effective regulatory response, and federal action on e-cigarettes should be a component of broader tobacco control efforts, including taxation, a renewed and strengthened Health Canada tobacco control strategy, a ban on all flavours and all tobacco products, and a requirement for plain packaging, package shelf warnings, and other measures.

Your questions are welcomed. Thank you, merci.

[The Chair, Conservative, Ben Lobb]

Thank you for your presentation.

Next up from the Heart and Stroke Foundation is Mr. Arango. Go ahead, sir.

[Manuel Arango, Director, Health Policy, Heart and Stroke Foundation of Canada]

Hello. I appreciate being here, committee members.

Today, I have the pleasure of discussing the issue of electronic cigarettes in Canada.

I would note that committee members have received a copy of our statement on e-cigarettes.

First, here is some information about the Heart and Stroke Foundation. Our mission is to prevent disease, save lives, and promote recovery. We're a volunteer-based health charity with 140,000 volunteers across the country and almost two million donors. We work very hard to impact the health of every Canadian family every day in every community from coast to coast to coast. Tobacco use is a key risk factor for heart disease and stroke, increasing the incidence of all forms of heart disease and stroke as well as other chronic diseases.

While we have made great progress in tobacco control over the years, reducing the smoking rate from 50% to 16% today, there is still a lot of work left to be done. Over the years the foundation has worked closely with its partners, such as the Canadian Cancer Society, and governments of all levels across the country, and we don't want e-cigarettes to reverse the progress we have made together on tobacco control. That's a really big concern for us.

Obviously I'm here today to speak about electronic cigarettes. As indicated by my colleague, these are a relatively new product category, and sales of them have been growing significantly over the last few years. They're also top of mind in the media and in the public health community.

I'll speak very briefly to some of the implications from a health-risk point of view, and also on some potential benefits.

The issue with e-cigarettes is that in terms of safety, we don't know what the contents are for some of these products. They vary from brand to brand. This is a real problem, because we don't have any standardized means of ensuring quality control in these products. They're available with and without nicotine, and both are a concern, especially from a renormalization point of view. The e-cigarettes containing nicotine, of course, are illegal in Canada; however, they are still prevalent.

While early studies and some anecdotal reports do indicate that e-cigarettes with nicotine have some potential as a smoking cessation tool, there still isn't enough evidence today for us to conclusively indicate that in fact they are a viable and effective tool. However, it is pointing in the right direction, so there is some potential promise.

Safety concerns, of course, are an issue because these products are unregulated. As my colleague indicated, it's the long-term health impact that we're really not sure about when it comes to e-cigarettes. The World Health Organization recently indicated that these substances are not merely water vapour, but they contain a lot of different chemicals, some with toxic or poisonous properties.

That said, and as also indicated by my colleague, they are likely a much safer alternative to traditional tobacco cigarettes, because we do know that with traditional tobacco cigarettes, the harm is overwhelmingly dangerous. There's significant evidence to indicate that, as we know.

It's also critical to determine whether e-cigarettes end up acting only as an add-on to cigarette smoking, resulting in dual use instead of complete cigarette smoking cessation. Also, researchers and public health experts are quite concerned that e-cigarettes could be a gateway to new tobacco addiction among those who have never smoked cigarettes before.

In particular, e-cigarette use is particularly appealing to youth. A study undertaken by the Canadian Cancer Society found that 18% of high school students in one jurisdiction in Canada—these are students who had never smoked before—had tried e-cigarettes, and another 31% were interested in using them. So it's a real concern.

Another issue, of course, is the marketing and promotion of e-cigarettes. Youth are targeted with the addition of attractive candy or fruit flavours. There are over 8,000 flavours being used worldwide right now in over 400 brands—or almost 500 brands.

In Canada it's illegal to make a health claim regarding an e-cigarette product's ability to aid in smoking cessation or to suggest that it's a safer alternative to traditional tobacco cigarettes. However, lifestyle marketing is common—and you've seen that in the ads that Mr. Cunningham has circulated to you. Also, companies often use celebrities and product placement to attract users.

Public health experts are concerned that if e-cigarettes are permitted to be used in public places and freely marketed, they could renormalize cigarette smoking behaviour and undermine our tobacco control and smoking cessation efforts.

In light of the need to maintain tobacco control efforts, and given the many unknowns around e-cigarette use, there has been growing demand for regulation in Canada and internationally. At all levels of government across the world there has been implementation of policies and regulations to address this issue. These include amendments to smoking acts, and complete bans, as have taken place in Brazil, Panama, Australia, and Israel. In theory, this could provide significant protection, but it could hinder potential cessation efforts if, in fact, these products are shown to be effective. For that reason, we don't recommend a complete ban.

Public-space bans are also very common in many cities across Canada and North America. These are a really strong means of protecting the public from second-hand vapours, and for preventing renormalization of tobacco smoking. As well, there are purchasing-age restrictions in many jurisdictions. These can protect youth from nicotine addiction and help prevent smoking initiation, but as also indicated by my colleague, these alone will not be sufficient.

These are some of the examples of how e-cigarettes are being addressed throughout the world and in Canada. As a result of this, the Heart and Stroke Foundation recommends—and this is found in the document that we circulated to the members—that the following actions be undertaken by the federal government to address all e-cigarettes.

The use of e-cigarettes in public spaces should be prohibited in workplaces where smoking is banned by law. For example in federal buildings, as indicated through the federal Non-smokers' Health Act.

E-cigarette sales should be prohibited to minors.

The advertising and promotion of e-cigarettes should be be strictly regulated. In particular, one of the things that we're concerned about is the co-branding of e-cigarettes with tobacco industry logos or brands. We don't want e-cigarettes being labelled as Rothmans, du Maurier, or Export A. That would only help to renormalize tobacco smoking.

The product should also be regulated. For example, flavour should be restricted. This is really important to prevent renormalization. As well, they should be visually distinct from regular cigarettes. E-cigarettes shouldn't have a filter, a glowing tip, etc. Having such would only help renormalization.

As well it's critical that Health Canada actively enforce the ban on e-cigarettes with nicotine. We know that Health Canada has sent out letters to retailers across the country to cease and desist, but we think in addition to this after a second infraction penalties should be applied to retailers that do not comply.

Finally it's very important to dedicate research funding to investigate this issue further. We need to determine what specifically are the long-term health risks and are these products potentially useful as a good quit aid?

In summary, Mr. Chair, the Heart and Stroke Foundation supports action on e-cigarettes. Taking into account the threat of renormalization and the creation of a new gateway to addiction and health risks, as well as the need for more information regarding the potential smoking cessation benefits of e-cigarettes, it's critical that the federal government move quickly to regulate all e-cigarettes and to commission further research.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

We'll go into our question and answer session. I think we'll have is five-minute questions and answers so we can get through as many as we can.

Up first is Mr. Kellway. Go ahead sir.

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

Thank you very much, Mr. Chair, and through you to our witnesses today. Thank you for attending and providing such great and informative presentations.

I have to say that in the way we do business here—and this has come up particularly in the context of this discussion of e-cigarettes—it's very difficult to get at some of the issues because for this issue or subject matter in particular, there seems to be a wide range of issues. In each of your presentations you covered a whole bunch of different matters and I find it difficult to pull the threads out and figure out what the positions are in each issue.

Let me start this way, if I could. It seems like there's agreement from everybody that there needs to be some regulation for the purpose of product or quality control. We've heard over and over again that there are multiple companies selling all sorts of different products containing this vapour substance with all sorts of different things. Are you both in agreement on regulation of product and quality control of electronic cigarettes?

[Rob Cunningham]

Yes.

[Manuel Arango]

Absolutely.

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

The issue that both presentations seem to come down to is a great concern about renormalization, the so-called gateway effect of this product. We had a previous witness for this study who talked about—and I'm paraphrasing because I can't remember exactly how he said it—how smoking is like being caught in a nightclub and a fire breaks out and that what you look for and want to have are as many exits as possible from the fire, i.e., from smoking, and that e-cigarettes are one of those right now. The immediate concern is the fire, meaning the tobacco.

That's an extreme kind of harm reduction approach to all of this. You guys seem to have a different concern and are suggesting that renormalization ought to be our primary concern. I'm wondering what research there is—I get the ads, I see the ads and intuitively understand their compelling effect—to base those profound concerns you have about renormalization of smoking and the gateway effect of this product?

[Manuel Arango]

Perhaps I'll just speak to the renormalization issue.

Research on renormalization is emerging right now, so we don't really have that much yet. However, what we base our concerns on is a lot of evidence in terms of human psychology and modelling behaviours. We know that modelling smoking among kids—when they see adults smoke—is an issue. It has an impact, and there is a lot of evidence on that.

So it is not a far-flung conclusion for public health experts to say that renormalization could be a potential issue. We'll know a lot more in the next two years or so, as more research comes out specifically on renormalization with e-cigarettes.

However, if you do look at research in other areas, in psychology, etc., it's very valid to be concerned about renormalization.

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

If I could push you on that a bit, though—and I don't know if this is the proper term—what about just normalization? If you apply those principles from human psychology and modelling effects, isn't smoking tobacco a bigger problem as a normalization for kids?

[Manuel Arango]

That is correct, from what we know right now, that tobacco smoking is much worse than e-cigarettes.

And yes, we don't want tobacco use to be normalized again.

We've done a lot in terms of changing the social norm in our society with respect to tobacco, and we don't want e-cigarettes to aggravate that.

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

Go ahead, Mr. Cunningham.

[Rob Cunningham]

You referred to advertising, and in terms of tobacco advertising, there is a vast body of research studies showing that it has an impact on youth and that it discourages quitting, which would have an effect on overall consumption. So I think there is a very good parallel that we can draw for the advertising of e-cigarettes.

[The Chair, Conservative, Ben Lobb]

That's great; you are right on time. Thank you very much.

Ms. Adams, you have five minutes.

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

Thanks very much, Mr. Chair.

Thank you very much for joining us here today.

I'm just looking through the advertisements you've brought in that are currently available in the United States. They seem to have quite a focus on consumers choosing the level of nicotine that would be in their e-cigarette.

Can you tell me what level and what types of nicotine or other components are permitted currently in the U.S.?

[Rob Cunningham]

In the United States it's unregulated. It can be any particular level or intensity within the liquid.

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

What are the components, and what are the health impacts and harms?

[Rob Cunningham]

Different e-cigarettes are manufactured in different ways. They have some type of battery. Some are disposable, but you'd use them a number of times. Some you could refill many times with liquid, and you'd buy the liquid separately. Those would be the fundamental components.

I think that in the United States, the Food and Drug Administration is looking at what types of potential regulation can be done, and they've had a consultation process on that.

In the European Union, a new directive was adopted in April—and there may already have been testimony on this. The nicotine threshold will affect the type of regulation an e-cigarette has, whether it would be regulated as a medicine/drug product or have other types of regulations that would be more similar to tobacco products.

[Manuel Arango]

I would just add one point to that. This was discussed at committee. I think a previous witness had raised it.

The question is whether, with some e-cigarettes, high heat would lead to the release of heavy metals into the lungs through the vapour as well. That's a question mark also.

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

I'm very glad to see that you've taken a strong position on smoking e-cigarettes in public places. Certainly as a mother, I for one would oppose the renormalization of cigarettes. I think it just leads to needless debates between patrons and businesses as to whether or not that e-cigarette ought to be smoked there. I'd hate for that type of modelling behaviour to be demonstrated to children.

But I do have some sensibility toward those folks who look at this as a possible way of finally kicking their addiction. Certainly I can understand that it might be helpful to maintain the actual habit of holding something up to your mouth, if you are weaning yourself off nicotine. I think that could conceivably be more effective to replace that habit, as opposed to just the patch, which is simply providing the lower and ever-decreasing doses of nicotine. There is something about just the habit of it.

You'll often hear anecdotally that people who are looking to stop smoking pick up increased coffee drinking or something else, just because they want that oral activity. So there is something to commend it.

Can you tell me, though, who might be doing leading research on how this could actually become a cessation tool?

[Rob Cunningham]

There is all kinds of research in the pipeline in North America and in Europe.

I think that in marketplaces where the e-cigarettes with nicotine are allowed, such as Britain and the United States, there is much more active research because it's easier to do.

Recognizing your earlier comments, the e-cigarette does provide a more efficient nicotine delivery system, and many consumers find it more satisfying than the patch. At the same time there are risks, and that's why regulation is needed. I think there is a general consensus of a need for regulation. There may be differences as to what regulation is best, although many recommendations seem to be coming up more and more.

[Manuel Arango]

Just to add to that as well, I take your point, and we don't want to throw the baby out with the bathwater, so to speak.

There are some good nicotine replacement therapies today. Perhaps they're not as effective as we would like them to be. Because you can hold a cigarette and it's going to allow people to feel as if they're still engaging in the habit, etc., that could be useful in smoking cessation. That's why a number of groups are interested in doing more research on e-cigarettes, to see if, in fact, they could be useful. There is some potential there, so we don't want to dismiss that.

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

To your knowledge, does any jurisdiction currently prohibit cigarette manufacturers from engaging in the e-cigarette business?

[Rob Cunningham]

Well, there are some countries that just prohibit the sale of e-cigarettes, period, at least e-cigarettes with nicotine, so no company could do it. But in terms of specifically making a distinction between tobacco manufacturers and others, I'm not able to identify a country yet that's done that.