Health Committee on Nov. 6th, 2014

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you again for having me back in my old committee.

Dr. Ostiguy, thank you for your presentation on electronic vaporizers, commonly referred to as "e-cigarettes".

As you are no doubt aware, they were invented in 2003 by a Chinese entrepreneur named Hon Lik. Most e-cigarettes are made in China. On the surface, they appear safer because they don't contain any carbon monoxide or tar. That being said, at this point, no one can guarantee their safety. Nevertheless, the e-cigarette market is developing quickly.

I looked at some documentation on the situation in my province, Quebec. This new way of smoking is all the rage among students. I read that 8% of students in grade 6 and 34% of high-school students had tried e-cigarettes between 2012 and 2013. The Canadian Cancer Society, specifically its Quebec division, had called on the government to take action and regulate e-cigarettes in the Tobacco Act.

What do you think the federal government should do about this new way of smoking? I am a doctor by training. The objective, as I see it, is to wipe out smoking in all its forms. Doctors are the ones who prescribe nicotine replacement therapy, but the product we are talking about today is available to anyone anywhere and is completely unregulated, from the manufacturing stage right to the point of sale.

What recommendations would you make to the federal government in that regard?

[Dr. Gaston Ostiguy]

You are reinforcing just how important proper regulations are. I, however, disagree with the figures put forward by the Canadian Cancer Society. From a methodology perspective, respondents were asked whether they had ever tried e-cigarettes. Everyone here today probably has children. Do you know a single teenager who hasn't tried smoking? Trying something does not mean taking it up as a habit. In its study, the Canadian Cancer Society asked people whether they had tried e-cigarettes in the past month or six months. They were not asked, one year later, whether they had continued smoking regularly. Like the Canadian Cancer Society's study, certain American studies do not ask respondents that question either.

In light of that, I think we should be looking to Europe, specifically England and France, which produce statistics on a monthly basis. Those countries could supply us with data on how many people regularly use e-cigarettes. Some argue that the price of e-cigarettes will drop over time. But a hundred dollars is a heck of a lot of money for a teenager to drop on an e-cigarette when they walk into a vape shop for the first time. That does not promote regular e-cigarette use.

What's more, the user has to have a bit of discipline. They have to fill the tank every two or three days and exercise caution when doing so. They also have to charge the battery and change the heating element regularly, as it wears with time.

At the end of the day, it's easier for them to walk into a convenience store and buy a pack of cigarettes than it is to use e-cigarettes. Using e-cigarettes requires some discipline.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

What worries me is the popularity among younger kids because it's as though smoking is cool again.

Most tobacco companies advertise, even if only at music festivals or rock concerts, as you mentioned, where everyone is vaping. So it's a real concern. It's become trendy like back when it was cool to smoke on television or in a play. On the surface, vaping is said to be less harmful, but no study has been done yet to prove that.

[Dr. Gaston Ostiguy]

Right now, the composition of the e-liquid and the levels of toxic substances, or contaminants, in an e-cigarette are significantly lower than what is found in a regular cigarette.

From a public health standpoint, there is something people often forget. The issue of dose-response factors into every type of illness, unless the cause is immunological. You have to have had a certain amount of exposure to a product in order for it to make you sick. Taking an aspirin will not give you a stomach ulcer, but if you take the whole bottle, you'll be in trouble. So the dose-response component is always key.

Even though nicotine, which is extracted from the tobacco leaf, contains toxins and contaminants, there should be some reassurance in the fact that the concentrations in e-cigarettes are 400, 500, even 1,000 times lower than those found in regular cigarette smoke.

[The Chair, Conservative, Ben Lobb]

Okay, thank you very much.

We gave Ms. Sellah a few extra minutes because she has come back to the health committee after being away for a while, so those extra minutes were on the house.

Thank you again, Doctor, for taking the full hour. That was a fantastic presentation you made.

We're going to suspend for a minute to allow our two other guests to get set up and we'll be right back in action.

Thank you.

[The Chair, Conservative, Ben Lobb]

Let's get started again. Welcome back.

We have two guests here for the last hour of our meeting today.

Dr. Bhatnagar, you go first please, then Mr. Sweanor, you can go after.

Go ahead.

[Dr. Gopal Bhatnagar, Cardiovascular Surgeon, Trillium Cardiovascular Associates, As an Individual]

Thank you very much.

It's certainly a pleasure to be here in front of this committee. Thank you very much for the opportunity.

I'll open by saying it's a privilege to be here because of a number of things. Coming up the street in a taxi, as an ex-serviceman and a father of a reservist, I had the opportunity to see in front of me that memorial. It was a very emotional experience. In addition, it's the week coming up to Remembrance Day. In fact, it reminds everybody that today in 1917 our Canadian soldiers took Passchendaele.

With that, I'll try to emphasize the same passion in my knowledge and support for e-cigarettes, and be happy to answer your questions.

I will tell you a little bit about myself. I'm not new to safety or innovation. I established a community cardiac surgery-based practice in Canada. We're now one of the three largest beating-heart surgery centres in North America, meaning we don't stop the heart-lung machine. We did that specifically to improve patient care, and we are lead benchmarks for surgery. I was chief of staff at our hospital, so having to look out for people who could not look out for themselves has been a great passion of mine.

After six months of research, I'll declare that I did find an e-cigarette retailer, but I also advise people to have heart surgery and am renumerated for it. In fact, every physician is remunerated for recommending their treatments, and I would not at all be involved in or stand in front of you to create any kind of bias. I would be happy to address any questions you may have in that regard.

In fact, this is the enemy. The smoking I see every day clogs arteries. That's what I make my living out of. It causes lung cancer.

This slide shows an individual in her last stages of palliative care, and we need to stop this. Of what you see in front of you, 85% to 90% can be prevented.

This slide shows the leading causes of lung cancer: smoking; radon gas we've been able to get rid of; asbestos we regulate and get rid of; air pollution. Air pollution is out there. It's not safe to breathe in our cities.

I want to address clearly some fundamentals of the safety of e-cigarettes for users. No adverse health outcomes were seen when primates were exposed to continuous high concentrations of polyglycol vapour. The primates and mice were put in a box and were given high concentrations to breathe for 12 to 18 months. Histological samples of the lungs were taken and we could find no chronic effects or changes in those lungs in the deep alveolar tissue.

When smokers are able to go off tobacco smoke, they experience immediate beneficial effects.

On pulmonary inflammatory disease, I tell my smoking patients they have to stop smoking two weeks before surgery. The risk of infections is far less because the immune system of the lung improves as soon as we get people off cigarettes, aside from it simply being a long-term cancer-causing agent.

I'm going to use some terms. I want to talk about cytotoxicity, and that's the potential to cause harm or cancer.

Essentially you take the liquids, you take your chemical, you put them on cell cultures and you study them under the microscope to see if there's any change in their DNA. Does it damage the cells in any way? What we see is that when you actually apply the polyglycol vapour, or e-liquid vapour, you see no cytotoxic changes to those cells. These can be fetal cells. They can be stem cells. So you can place it directly on these cell cultures without any effect.

If you do the same thing with extracts from tobacco, even down to a 5% solution of tobacco extract, it causes mutations in the genes of those cells.

In terms of the safety for bystanders, remember that a regular cigarette burns at the end. If you're sitting there and you're a bystander, you're getting the direct effect of that. Any vapour that's inhaled from an electronic vaporizer is first absorbed into the user. What comes out is what's left after absorption, and it's typically just a polyglycol vapour. There are very small amounts of nicotine in it. There have been studies that have shown bystanders will be exposed to nicotine. If you actually take a look at the way those studies were done, it was vaporized into a box. Essentially, to put it into context, you would have to lick the entire inside of the box to get any meaningful amount of nicotine, if you're a bystander.

If you take a look at heavy metals that can be possibly produced in it, they are detectable but are less than 1% of threshold values that you would consider safe if you were to walk into any factory or workplace today. And that's for the user. The bystanders are going to get even less.

I only put up this slide to simply show you there is no mystery around what's in vapour.

Chemical chromatography, liquid chromatography...we can identify all the chemicals that are in there. It's not a mystery. We know that every one of those chemicals, if they exist or are detectable at all, exist at threshold levels that are well below occupational health and safety standards, even if you provide a factor of 10 as a safety margin. This slide shows the same.

This slide compares Nicorette inhaler mist compared to that found in electronic cigarettes. We can see that if you were worried about formaldehyde—a lot was made about formaldehyde—the original FDA trial said there's formaldehyde in it....

There was a question earlier on in the session about the temperature of vaporizers. E-cigarettes vaporize at about 60 degrees. If you vaporize polyglycol at 280°C, in fact you burn it, you will create trace amounts of formaldehyde. An electronic device is incapable of creating that temperature. What we see is a profile of toxicity that's similar to something that's already approved today, that being the nicotine mist vaporiser.

Our youth are very important. I have kids. I don't want them to be exposed to anything toxic. I don't want it in our schools either. But what's the reality? If you take a look, unfortunately, kids somehow get cigarettes. They're banned and they're not supposed to get them, but still they do. We see, shockingly enough, as I was telling my son, that one in 100 of kids in grades 6 to 9 smokes cigarettes. Where do they get them from? We know that by the time they're teenagers, we have rates as high as 14% of kids who are not supposed to have tobacco in their hands or have it available, but somehow they get it. So for me the issue is, why are 14% of our kids smoking?

If we take a look at the United States, the current user prevalence in U.S. adolescents, have a look here, if you take a look at e-cigarettes only, up to about 25% is a very small part. Most are in fact dual users of the ones who use electronic cigarettes.

This study was performed in the United States and it shows a drop in smoking rates. If you take the top and you say, well, the use of electronic cigarettes has doubled. We see young people walking around with electronic cigarettes, it's an epidemic. But, in fact, if you take a look at it, very few of them are using e-cigarettes only. Almost all of them, 99% of them, are previous smokers. When I look at a slide like this, yes, I can worry about the 0.6%, or I can really be dreadfully afraid of that 11.8%, because if you started smoking as an adolescent, your profile of getting emphysema, lung cancer, and heart disease, is huge over your lifetime.

With regard to nicotine safety, nicotine is an alkaloid. It's found in plants. It's made in their roots. You can find it in eggplants, tomatoes, black peppers; it's in the highest concentration in tobacco. Why does tobacco actually have nicotine? It's an insecticide. It protects the tobacco plant from being eaten by insects, so that's why in days gone by high doses of nicotine were used as an insecticide. In fact, a question was raised about the toxicity of nicotine. In industrial-available strength, nicotine is toxic. It will cause seizures and vomiting, and it can be lethal. Outside of an industrial factory, those concentrations of nicotine are not available.

It does not cause cancer. It can be addictive, but there are no serious health care outcomes related to nicotine alone in the concentrations that are available today. Much is made about a child eating or drinking nicotine. Most likely if that happens, they will vomit. It is not fatal. They will vomit even if they like the flavour. They will take it, it will irritate, and they will vomit.

With regard to nicotine safety compared to analgesics, liquids, cosmetics, vitamins, there are very few—618—annualized calls to poison control centres, compared to over 200,000 calls for something like cleaning liquids and cosmetics.

On nicotine as a gateway to other drugs, the Polish study was mentioned. However, in a huge U.K. study as well, and if you take a look in Germany, the number of electronic cigarette users as a percentage is always around 0.1% in youth. There's no molecular mechanism or clinical mechanism, aside from a very small Polish study, that would indicate that people will start with electronic cigarettes and move on to something else.

I want to emphasize that.

Smoking rates have gone down very consistently since marketing has been started to counteract tobacco advertising. But we've plateaued. In fact, now we're in the endgame for a tobacco-free society. That's where I certainly echo the sentiment of physician members and committee members. I would like to see a tobacco-free society. How can we let this occur? We've got the low-hanging fruit. The people we could get off tobacco, we've gotten off tobacco by every means. What's going to get us down to 0%?

Much is made about smoking cessation. The ITC studies say that people who incorporate electronic cigarettes in their regime cut back their exposure to cigarette smoking from about 20 to about 16. It's helpful in reducing emphysema, cancer, heart cessation rates because it's a dose-dependent phenomenon. The more tobacco you take, the worse it is. So you don't have to go from up here to zero; coming down on the scale is beneficial. We can see here, lung cancer in men, cigarette consumption in men. The more you smoke, the worse it is. You move people down that scale, you lower their risk.

Once again, I want to emphasize a lot: tobacco harm reduction. Cessation is an all-or-nothing phenomenon. Tobacco harm is proportional.

This is a great slide. I draw your attention to it. The fact is, if you can reduce people's cigarette consumption, you reduce their relative risk almost exponentially. Take a look at people taking a pack a day in that pink bar. You get them down to 10 cigarettes a day and the trials, both Burstyn and Polosa, have shown that you can reduce cigarette consumption by about 50%. So you're taking people down into that very low column. Are they at a higher risk than zero? Unfortunately they still are. But you've reduced their risk twofold.

In smoking cessation therapy, we can take a look at e-cigarettes and they have gone up. There's a reason they've gone up. Despite all the thinking that experts have, we have failed smokers in being able to get them off cigarettes. We can applaud ourselves about our medical therapy, about our pharmacology, about our drugs, but one in five Canadians still continues to smoke.

I would congratulate you on many respects but one is that you have undertaken more due diligence at this committee than has been done by the FDA, by the World Health Organization, and by the CDC. None of those august organizations that many of the population depends on for clear and accurate information undertook this level of diligence. When you read statements from the World Health Organization, the FDA, and the CDC, those decisions were made behind closed doors. Their review process was not transparent at all. I don't really understand why they say what they did. On the re-normalization of smoking, the gateway phenomenon was attributed to Mark Frieden. He is the director of the FDA. I don't know why he believed that. I have no idea why he made those statements but he did. Because he's director of the FDA, everybody puts credence on that.

I'd like to conclude. I know I'm running short on time. I don't want to take any time from my august member here. So, available cytotoxic and chemical analysis shows e-cigarettes have a risk profile that is orders of magnitude less than traditional combustible. Nicotine does not cause cancer. Tobacco kills people. There's no evidence on a molecular level from the New England Journal of Medicine or epidemiological studies aside from only one that e-cigarettes are a gateway to progressive use of worse substances. Tobacco use in our youth remains the concern. In fact, the presence of e-cigarettes could be argued to be reducing the use of combustible products. Flavoured cigarettes, although they have been available in Europe for a decade...still only .1% of all e-cigarette users are youth.

Research indicates that second-hand vaping is not a concern.

My suggestions are—I'll run through these; I believe we can all read—that a new category of tobacco harm reduction tools should be created because we cannot predict the future. Let's create a regulatory and structural framework where we can continue to evaluate new products and tools as they come along.

We certainly need to have manufacturing standards for hardware, the battery composition and duration, and you need to establish standards for your liquids. People cannot be making this stuff up in their garage. That's not what we want. We need manufacturing facility requirements. We need labelling. I believe that nicotine can potentially be toxic in high concentrations. We need a lot of tracking mechanisms to know about product recalls and ingredient quality. Certainly, they need to be bottled in a way that it's as difficult as possible for children to get at it. Restricting the sales and products, I think we've been over that.

There is some sort of statutory warning perhaps for women who may be pregnant because there might be some effect on very early fetal cell tissues. In principle, I think there should be some advantage to using electronic cigarettes financially and socially over using a traditional cigarette. I'm not going to suggest exactly how that is. Any type of lifestyle advertising should be banned. I believe that it should be promoted as a tobacco harm reduction strategy. Much has been made on the sale of youth flavours. I'll leave that and answer that during the time for questions, but it should be based on consumer demand.

Increase taxation of tobacco products if we think we're going to lose taxes by the use of tobacco products. Make it more expensive to use whatever tobacco products there are out there, but give some incremental advantage. I believe that the same health care organizations that are saying that there's insufficient evidence should be charged with funding unbiased brand-neutral trials. A standing committee of tobacco harm reduction should be part of the health protection board, that I have occasion to deal with and have helped me to treat a great many patients over the years.

Thank you very much for your attention.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

I'm glad you touched on a couple of topics. One is the combustion of the propylene glycol because that's come up a couple of times and the recommendation on milligrams per millilitres in a capsule.

Professor Sweanor, go ahead.

[David Sweanor, Adjunct Professor, Faculty of Law, University of Ottawa, Special Lecturer, Epidemiology and Public Health, University of Nottingham, England, As an Individual]

Thank you very much. It's a pleasure to be here.

I'm a lawyer. I've spent now over 30 years working on public health policies on tobacco in Canada and around the world. I've testified in front of quite a few committees over the years and I think it's fair to say we've literally made history on other issues of tobacco in Canada.

When I first got involved in the beginning of the eighties among 15-year-olds to 19-year-olds, 42% in Canada were daily smokers, and in the space of 10 years we got that down to 16%. That was policy. We led the way on using things like tax policy, advertising restrictions, package health warnings, smoke-free spaces. A few people now remember we were the first country to get smoking out of airplanes. Now many of us have trouble even remembering how awful that used to be, but it was because of things like this.

And I must say, at a personal level, it's fair to blame my wife on some of this because as I was a young lawyer starting out, deciding I was going to change the world, she was a young doctor, and she was talking about how many people were sick, how many people were in hospital beds because of smoking. And at one point I said, “Well, if smoking is as big a problem as doctors say it is, you ought to be doing more about it.” She said, and she's usually right, “You don't get it.” And this was not the only time in our relationship she said that. “Figuring out why people are getting sick is a medical-scientific problem. Dealing with it is a social-legal-political problem. It's up to lawyers and politicians to deal with it.” And I think she's right, and I've been spending over 30 years trying to deal with it. And that's why I think we're here today.

We have had these great successes. We've reduced per capita consumption of cigarettes in Canada very dramatically over that 30 years, probably by about two-thirds. But because of an increase in population and the fact that a lot of people reduced, but didn't quit their smoking, the total number of smokers in this country went from just over seven million to somewhere around five million. It's still our leading cause of preventable death.

I have no written submission for the committee, but what I'd highly recommend is that Clive Bates, who was to testify here, has sent in a very good submission. I think Clive, who is a friend and a colleague for many years out of the U.K., is one of the best thinkers we have in public health on tobacco. And instead of reading anything that I would submit, I suggest you read what Clive submitted twice. It's that valuable.

If the committee is interested, I can certainly submit other things that I've written over my career, including on this topic. I should also say that I have no financial conflicts of interest. I don't get money from anybody on any side of this, whether it be people trying to sell the products or people trying to oppose the products.

Why are these things important? Why is it we're talking about them? Well, frankly, it's because cigarette smoking is still by far our leading cause of preventable death. It's still killing somewhere in excess of 40,000 Canadians per year. Based on the status quo, if we simply continued to do the things that we're doing now, we can expect another million deaths in the next 25 years. Those are all totally preventable. We can do something about it.

And one of the really odd things that I've experienced in my career working on this is that we have done all sorts of things about the periphery of the cigarette, but not dealt with the cigarette itself. We've not dealt with the fundamental problem. We've talked about things like what price because of taxes you have to pay, where you can buy it, who can buy it and who can sell it, where you can use it, what sort of labels you need to have on it, and what sort of advertising there will be for it.

But the product itself is the fundamental problem because cigarettes are just an incredibly deadly delivery system for a drug. If people got their caffeine by smoking tea leaves, it would also be killing a tremendous number of Canadians because essentially, it's the smoke. As you've heard from others, we know that smokers smoke for the nicotine, they die from the smoke, and the public health tragedy is that they don't need to. Even if they were going to use nicotine, they can use nicotine in a way that simply doesn't cause those problems. As I've been saying, we haven't worried a whole lot about people drinking tea and coffee. It can be addictive; there are risks. It's low enough that we don't worry much about it. If they were smoking coffee beans, smoking tea leaves, it would also be a huge problem.

We've known for decades that we could reduce the problem. We could essentially eliminate the problems by simply getting rid of combustion-based delivery. And we now have products that are coming onto the market that provide that sort of opportunity.

Wells Fargo, the giant investment bank, has estimated, and their belief is, that within a decade electronic cigarettes will outsell cigarettes in the United States, depending what sort of regulation facilitates or gets in the way of that happening. That's a huge opportunity.

What we're seeing here is something that I think follows the history of what we've seen in other areas of public health, whereby we're getting an intervention that isn't a medical intervention per se; it isn't because of government or health departments telling people what to do. This is coming from entrepreneurs who come out with a product to meet a demand from consumers who are saying, I don't want to smoke; I want something that will help me get off smoking.

People are incentivized to come out with better products. Among other things, people are spending $700 billion a year buying cigarettes around the world. Most of those people don't want them.

This is similar to what we've seen before. In the early 1940s, the leading cause of cancer death in Canada wasn't lung cancer, which is by far our biggest problem now; it was stomach cancer. Stomach cancer deaths fell precipitously, and they fell not because of a hugely expensive government intervention; they fell because entrepreneurs leveraged innovative technology to meet a consumer demand—for refrigerators. We used refrigeration; diets changed; stomach cancer rates plummeted.

Look at what happened with automobile death rates. When I was young.... I think all of us growing up, certainly in small-town and rural areas, can name lots of friends who died in car accidents. More than 6,000 Canadians were dying each year. It's fewer than 2,000 now, even though there are more than twice as many cars on the road. We changed the delivery system; we changed the product; consumers were able to access something; entrepreneurs were incentivized to come out with better auto safety features. The death rates are down by more than 80%.

When we look at nicotine, we could do something that would lower the death rates far more dramatically and far more quickly, and we simply have to figure out how to seize that opportunity. How do we de-normalize smoking? That's what these products can do; they are a fundamental threat to the cigarette status quo.

It's very hard to imagine somebody now wanting to get into a car that doesn't have air bags, seatbelts, safety glass, etc. It's very hard to imagine somebody wanting to buy the snake oil medicines that existed in the 1930s now, rather than modern medicines.

We have the ability to give a real option to smokers, and in doing that we have the potential to then use the tools we've been using to try to reduce smoking—regulation, litigation, etc—to further change the market. I think we have the potential to make cigarettes history; to make one of the biggest breakthroughs we've ever had in public health.

In terms of how we do this, a key thing is to identify what not to do, because I think we've been seeing a lot of that. I don't think we need to engage in moral panics; I don't think we need fearmongering; I don't think we need people hyping potential, minor, hypothetical, and containable risks; I don't think we want to use regulation that protects the cigarette business because of some fear that something might go wrong with products that are massively less hazardous. We have to be aware that the unintended consequences people worry about have to be seen in relation to the 40,000 deaths a year by cigarettes.

That's the problem. How are we going to avoid being held responsible in future years for having maintained that epidemic when we had the option to do something about it.

What should we do?

I think we need fit-for-purpose regulation. There's a tendency for people to look at the regulations we now have on nicotine and say that it has to be a medicine or it has to be a tobacco product. It isn't either of those. Just as, when somebody says “sort these blocks into squares and circles” and then hands you a triangle, it's important to say “I need another pile; this isn't either of those”, we need to look at regulation that is aimed at getting the most effective measures in place to move smokers off combustion-based delivery and get people on to not just the e-cigarettes that exist now, but to wherever innovation will take us.

We have, even here in Canada, leading medical researchers who are developing what I think are phenomenal products—products that could be far more effective at getting people off cigarettes but that are stymied by regulations—saying, we can't market them in Canada; the barriers to getting these things into the market are simply too great. We need regulation that opens up the opportunity to do things such as that.

We need to have truthful, non-misleading information to consumers. The history of public health tells us that often the biggest breakthroughs are based on two very simple concepts. One is that you give people enough information to make an informed decision; and two, you give them the ability to act on that information. If we do that, amazing things happen when people are able to act.

Look around at what is now happening with electronic cigarettes. As you've heard from other speakers, in the U.K. the anti-smoking groups there estimate that more than 700,000 smokers have totally switched to electronic cigarettes. There are higher numbers in France.

In the U.S., with the best numbers I can see, over two million have already switched entirely to these products. These are huge potential breakthroughs, but it's very much the general patent line, “there's no such thing as an obstacle, only a new opportunity”. Rather than looking at this and asking what might go wrong, let's think of what might go right. What could we do that brings us within the realm of what we've had a history of doing in Canada, of getting public health right and setting precedents here that save the lives of a heck of a lot of Canadians and that are then exportable to the rest of the world as good public policy?

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

You referenced a colleague of yours and his material. Just for the committee's records, that information was distributed. Our clerk was able to get this information. It was distributed on November 4 in the morning. If you want further information, check your inbox or your staff's inbox for that.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Do you have a copy for me?

[The Chair, Conservative, Ben Lobb]

Your friend to your left will give it to you.

Okay, Mr. Morin, you're up for five minutes.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Isn't it seven minutes?

[The Chair, Conservative, Ben Lobb]

It would be, but in order to get around we'll keep it to five minutes, but we'll be lenient.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

That's not a problem, thank you.

Dr. Bhatnagar, thank you so much for your presentation. It is very thorough work you are giving us today.

Regarding your suggestions, I have three of your suggestions on which I'm not fully convinced. I'm going to give you more opportunity to convince me, as a member of Parliament, to go along with some of your suggestions. A lot of them make total sense.

You asked for wider latitude for public use indoors. I do understand that the grand goal is to move people away from cigarettes and toward e-cigarettes or other ways to decrease the usage of cigarettes, but my fear is about the normalization of smoking indoors, in restaurants and maybe in schools. If a teacher in class wanted to smoke e-cigarettes, according to your suggestions, that could be allowed.

Could you explain or expand on this?

[Dr. Gopal Bhatnagar]

By “latitude”, I don't mean freedom. I would be appalled if a teacher stood up in front of a class and used any type of vaping device. I certainly think that is not on.... I also believe that in a confined space, a workplace, there is the science and then there is the social custom. It is impolite, whether it be safe or not, for me to vape if somebody is there beside me, science aside. Where I would suggest there are possibilities in promoting the public good is in night clubs. Perhaps there is some opportunity there.

Is there some opportunity in the public spaces at the base of a condominium or in an office building, not in the office itself, or some area that's set aside such as a large lobby area where a vaper can use it indoors and the only small incremental advantage you're giving them is if they're using a vaping device they don't have to go outside and stand in the cold? Essentially, if you gave them even that little sliver that would be a huge bonus, especially in Canada in the wintertime so that they could stay inside and stay out of the sleet and snow, whereas those using tobacco products would be outside.

Otherwise I do believe there should be significant restrictions on its use.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you. That helps to better understand that recommendation.

You also recommended not restricting sales of e-cigarettes to tobacco retailers. Where would you want those e-cigarettes to be sold? Would it be in the specialty shops that were mentioned earlier or drugstores to receive the input of pharmacists regarding their use? What do you think?

[Dr. Gopal Bhatnagar]

To be clear I just wanted the sale of an electronic cigarette not be tied to the sale of tobacco. I don't believe it would be in the public's interest to say, “where tobacco is sold is the only place you can sell electronic cigarettes“.

The electronic cigarette, or vaporizer, comes in two forms. One is disposable. It's a self-sealed thing. You use it until it runs out and you throw it away. Those are the ones you see sold at gas stations. They require absolutely no information. You just open it, you pull off the peel, and you can start using it. For the more sophisticated vaporizers—selling them in pharmacies, Walmart, Target, places like that—it's going to be an economic failure because they do require instructions to use, so you need motivated staff. You need time.

Leaving that type of product in a pharmacy is probably not going to financially do well for the pharmacist. The disposable e-cigarette, which is just a plastic tube, the simplest thing, may be perfectly fine.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

For my other question, you talked about increasing taxation on tobacco products to compensate for the loss of taxation income from e-cigarette use. I'm not a fan of tobacco, but I wonder if by increasing the already high tax on tobacco products it would push more people into illegal regular cigarettes. That's why I want to have your input on why you think it is still a good option and will not fuel the illegal regular cigarette market.

[Dr. Gopal Bhatnagar]

Fair enough. These are the pros and cons that certainly have to be weighed. We see the economic curve of price and use. Pragmatically, though, if as predicted by Wells Fargo electronic cigarettes are taking over tobacco, the taxation income from tobacco will decline. At some point in time it will decline. However, there will be a time lag in which you will see the health benefits. when those health benefits start accruing, if we see cancer rates drop, emphysema hospitalization rates lower, we'll see a savings on the health care front, but something will need to be done to make a leeway. I think there are people far better qualified than me to discuss the economics of what tolerance there is for increasing taxation as opposed to not driving that illegal market. I have no clear answer for you about how to control the illegal market of tobacco. I would only say, though, that the corollary is true, that if you increase the taxation on electronic cigarettes there's a clear problem with a black market e-cigarette. You can make these devices in your garage at home. There are YouTube sites where people will make these devices and make the solutions at home that have no standard. If we make it inordinately expensive or even equally as expensive to acquire, then you'll see people start making these things at home and then you will see more batteries explode and people being poisoned by them. That's why we need regulations.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mr. Young, go ahead sir.

[Terence Young, Conservative, Oakville, ON]

Dr. Bhatnagar, we've recently done a study on opioid use and on marijuana use and the health risks related to that. We have huge addiction problems in Canada. So it's not only tobacco that's the problem, it's addictions that are the problem. Addicts are diminished. They lose control of their lives. Their thoughts are interrupted regularly during waking hours by urges they can't control. They spends hundreds and thousands of dollars annually, depending on their drug of choice, to satisfy unnatural cravings. Teens as young as 12 regularly get drunk, practice binge drinking, and some of them develop lifelong addictions. Teens as young as 12 are addicted already, or beginning an addition to tobacco and marijuana, which also leads to a range of serious health issues later in life including brain damage and lung cancers. Teens as young as 12 are becoming addicted to opioids, other painkillers and prescription drugs, tens of thousands of them. We know that our young people are getting their hands on all these substances. In my view we have failed all these young people. Now there's a new way to get addicted, which is e-cigarettes, and they're already using them.

My question for you is how can we protect our children and youth from the drug and alcohol and nicotine dealers, and don't we owe that protection to our youth, and don't we owe our youth the best that we can do to protect them from those addictions?

[Dr. Gopal Bhatnagar]

Mr. Young, the answer only to that is yes, of course, we do have a duty from a medical perspective, from a policy perspective, from a political perspective, to protect our youth from harm. There's no doubt about that. I don't hazard to provide you any opinion on how to improve alcohol addictions and opioid addictions. I know in Canada chronic pain management is poorly treated. It's a systemic problem for chronic pain.

[Terence Young, Conservative, Oakville, ON]

Doctor, you appear here under two roles actually.

[Dr. Gopal Bhatnagar]

I suppose that's true, yes sir.