Evidence of meeting #41 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was e-cigarettes.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Gaston Ostiguy  Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual
Gopal Bhatnagar  Cardiovascular Surgeon, Trillium Cardiovascular Associates, As an Individual
David Sweanor  Adjunct Professor, Faculty of Law, University of Ottawa, Special Lecturer, Epidemiology and Public Health, University of Nottingham, England, As an Individual

11:35 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

Yes. Again, we need to have some retrospective long-term studies to show that using the electronic cigarette does not lead to a relapse to tobacco.

We don't have any evidence for this, and if we look at the European literature, the European experience, it hasn't been so.

11:35 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

We do. We actually have that in Poland. They have an example where having e-cigarettes available has led to new uptake of combustible cigarettes but that seems to be an outlier. We don't seem to have any other evidence. That's why I'm asking if you are aware of any other evidence.

11:35 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

No.

I think Poland is probably the only country that has reported such a thing. But if you look at the French experience, the Scandinavian experience, the British experience, which is extremely well documented, this hasn't been their experience.

11:35 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Doctor, you made some recommendations that if e-cigarettes were to be regulated in Canada you would recommend that there be some gradients on the e-cigarette itself so that people can understand how many cigarettes they're smoking. What level of nicotine and what other recommendations would you have to offer?

11:35 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

Again, when you see a smoker, of course you evaluate him and you ask him how many cigarettes he smokes. To give you a proper idea of the number of cigarettes he smokes, we measure his alveolar CO. If somebody comes out of the clinic with CO of 12 ppm or 18 ppm he will not be given the same concentration as somebody who comes in with 45 ppm CO in his alveolar air. You know that from the rules in the workman's compensation board, if you go over 50 ppm in a shop the CSST would close the shop.

11:35 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Are you suggesting doctors serve a parallel system then, where somebody would come in and meet with their physician regularly and under the advice and monitoring of their physician they would end up eliminating their addiction to nicotine, and then there would be a separate parallel system where e-cigarettes would be available at specialty shops as you mentioned or as readily available as cigarettes currently are in convenience stores?

11:35 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

Well, of course, in our experience we use it to help people to stop smoking and for harm reduction. But again, tobacco cigarettes have been on the market for years and no new government has ever been able to ban the sale of these cigarettes. I think that nobody thinks it's going to be possible. So tobacco cigarettes are always going to be there.

If we have to be realistic and say that you will always have a certain number of smokers in the country, it is certainly going to be less harmful for them to use the e-cigarette than the tobacco cigarette because nicotine, like I said, is not harmful to your health. I mean, is it really worse than coffee? Are you going to close all the Tim Hortons shops? Probably in terms of physical effects on your cardiovascular system it's not much different from coffee and nowadays you see everybody coming to work with a cup of coffee in their hands and we don't care about this, really, at the moment.

11:35 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

A gallon of coffee sometimes....

Sorry, again, I'm just putting this out there to understand your opinion and your recommendations. If Canada were to move forward and regulate e-cigarettes with a nicotine content, for instance, make it available at convenience stores only to those 18 years of age or over, only to those with ID as we currently do with tobacco, what would you propose that we do with e-cigarettes that do not have nicotine currently?

11:35 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

There have been some studies, and this is also our experience, that for some people the ritual of smoking, the blowing out of some vapour, is very important for them.

Yesterday I had a patient who had a cerebral haemorrhage. She had neurosurgical surgery. She walks with a cane. She wants to stop smoking to preserve the integrity of her vessels and she doesn't want to use the electronic cigarette with nicotine. But in the past she already bought the e-cigarette without nicotine and it was helpful in her case. So along with nicotine replacement therapy she wants to use the electronic cigarette without nicotine. There have been some publications, and I don't have the reference offhand, showing that the ritual of smoking is also very important for people...to vape or to smoke.

As long as the flavours are innocuous also.... This is one thing. We don't have much information about the flavours. But they need to be there because this is what makes the e-cigarette appealing and usable. We have to have some control over this to make sure that the flavours are not dangerous.

11:40 a.m.

Conservative

Eve Adams Conservative Mississauga—Brampton South, ON

Do you have any suggestions in terms of ensuring that those who are under 18 don't get their hands on e-cigarettes even if they do not contain nicotine?

11:40 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

If we look at the experience of tobacco cigarettes, we should at least apply the same rules for e-cigarette in terms of selling e-cigarettes to people under the age of 18. But you know as well as I do that it hasn't always been that successful and that easy to apply.

But again, if you select a certain number of reliable shops and then you make sure that these people don't sell any products to minors.... We are aware of some of these shops where our patients are going and the owners are assuring us that they're not selling any e-cigarettes.... They ask for identity cards before selling e-cigarettes to these people when they look too young.

11:40 a.m.

Conservative

The Chair Conservative Ben Lobb

Ms. Fry.

11:40 a.m.

Liberal

Hedy Fry Liberal Vancouver Centre, BC

Thank you very much, Doctor. I just wanted to ask you a couple of questions.

We heard from other witnesses that there isn't sufficient—and I recognize that at the hospital you are at, you are doing some of this clinical research work yourself—evidence of the efficacy of e-cigarettes as a harm reduction technique. They say they think it is, but there isn't enough clear research. That's the first question. Do you believe there is clear research? Do you believe this constitutes clear research, or should there be more research done?

We've also heard that there is one major danger of e-cigarettes in the home. The liquid can be highly poisonous to children if it gets into their hands. That's the second question. What would you suggest—other than telling parents to take care, and we know how parents leave bleach and all kinds of things that are household hazards for their kids—to diffuse that poison risk or bring down the poison risk? What do you think of the research to ensure that this, in fact, is an efficacious form of either quitting or helping people to quit, or harm reduction?

11:40 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

If you talk to almost any clinician like the ones who have been writing these books, if you think of the experiences of Dr. West and Dr. John Britton in England, they have much more experience with e-cigarettes than we do.

I could tell you some success stories. I have a patient with emphysema and he could hardly walk a block without stopping. He used to be in the construction business. He had to stop two or three times when walking from his car to the clinic. He used to come to the emergency three or four times a year because of exacerbation of his emphysema. He was admitted about once a year. He was taking prednisone and antibiotics every two months. We gave him Zyban, Champix, patches, gum, and lozenges. I did not invent that recipe. If you look at the publications coming from the Mayo Clinic, Dr. Hurt over there is doing those sorts of things. We were unsuccessful. So last October....He was our first patient and he was smoking more than 75 cigarettes a day. He switched to the e-cigarette and now he is still on the e-cigarette at a nicotine concentration of about 5 milligram per millilitre. He has had no exacerbation of his COPD this year, no antibiotics, no cortisone, no admissions to the hospital, no visits to the emergency. Now he has taken one of his rooms to build himself a gymnasium to exercise.

These are the types of success stories that we have, so it's difficult to say that it doesn't help people to stop smoking, and it doesn't help people to improve their health.

I had this young lady who was an asthmatic. She had not jogged for five years and she was on inhaler medications. She started to use the e-cigarette and when she came to the clinic, she didn't want to tell her chest physician that she stopped all her pumps, but she did and she has resumed jogging.

We have patients who have switched to the e-cigarette, even if they haven't stopped completely using tobacco cigarettes—like I said before, many of them are only smoking two or three—but they are planning to stop eventually. All of them, 100%, are feeling better.

However, to carry out prospective studies, especially with hard-core smokers, to tell you the truth, I think it would be unethical at the moment with the experience that we and other clinicians have about this. We have to rely on well-documented, retrospective studies.

11:45 a.m.

Liberal

Hedy Fry Liberal Vancouver Centre, BC

I want to ask you about liquid nicotine and kids.

11:45 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

If you do provide nicotine in childproof bottles, you cannot even get your nicotine solution with a syringe because it's like a dropper. Children will have extreme difficulty to get intoxicated with nicotine. Christopher Columbus brought nicotine to Europe in 1492, so it is a product that has been on the market a long time. I don't think there's any substance that has been as well studied as nicotine.

11:45 a.m.

Liberal

Hedy Fry Liberal Vancouver Centre, BC

Thank you.

11:45 a.m.

Conservative

The Chair Conservative Ben Lobb

Thank you very much.

We're going to go to Mr. Lizon now for seven minutes.

11:45 a.m.

Conservative

Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON

Thank you very much, Mr. Chair.

Thank you, Doctor, for coming here this morning.

I would like to hear clarification from you. You did mention in your presentation that smoke in cigarettes kills people, that's the main cause of lung cancer. Lung cancer is the leading cancer among Canadians, which is a reason for concern. Nicotine does not kill, but can you clarify for me, is there a negative effect of using nicotine in any form on the human body?

At the last committee meeting we had people here who work in the toxicology field. They made a presentation before the committee and spoke a lot about how toxic nicotine is and how strong a poison it is. Is there a negative effect of nicotine in any form on the human body?

11:45 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

It doesn't cause cancer, never caused cancer, I never saw any cancer related to the use of nicotine by itself, and it doesn't cause any pulmonary problems.

The cardiologists tell us that the use of nicotine could slightly increase the heart rate and slightly increase the blood pressure. It's minimal and for them it's not significant compared to the use of tobacco cigarettes.

I cannot tell you that nicotine is completely innocuous in terms of health effects, but the product by itself has so little effect on human health. In the second slide I showed you see the list of diseases related to tobacco smoking and the only thing that is related to nicotine is dependency or addiction.

11:45 a.m.

Conservative

Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON

On treating nicotine addiction, you mentioned that it should be personalized and everybody is different. I think this applies to any addiction, whether it's an alcohol addiction or a drug addiction. We have centres all around the world that treat people with different addictions. Is there a standard way to treat people addicted to smoking, or is this something that different doctors would try different ways of approaching? If it is, what role will e-cigarettes play in the process of treating the cigarette smoking addiction?

11:50 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

There are two basic, principal issues.

If you look at even the third edition of the American guidelines on how to treat smoking addiction, there are two basic principles: pharmacotherapy and counselling Very often, if people really want to stop smoking and have made many attempts in the past and have had lots of difficulty stopping, you should use these two approaches. But again, I'm a bit disappointed and discouraged to see how.... It's so easy to use a standard recipe for everybody, but this is why it's so unsuccessful at the moment: they don't adapt.

For example, the main cause of failure, in my experience.... I've been doing this for quite a few years now, as you know. I have been involved in the tobacco business since 1975 and am one of the founding members of the Canadian Council on Smoking and Health. In our experience, the main cause of failure of nicotine replacement therapy, for example, is that people don't start at a high enough dose of nicotine replacement.

Even nowadays, smokers remove their patch to light up a cigarette. If they cannot resist lighting up a cigarette while they're wearing the patch, there's only one reason: it's that they're not getting enough nicotine. People are not using combined therapy. The patch will provide the smoker with a constant concentration of nicotine, but it will never provide the kick that the brain is asking for when the smoker lights up a cigarette.

We've been trying to approach some medications that will deliver nicotine much more quickly. We started with the gum, then went to the lozenges. But nicotine is absorbed by the mouth and goes through the venous system, not the arterial system, which goes right the brain when people light up a cigarette.

And then you have the inhaler. There is one inhaler at the moment that is providing the patient a fairly high concentration of nicotine and fairly quickly—less quickly than the tobacco cigarette, but again, much better than the gums and the lozenges or the other forms of inhaler.

As you know, the nasal spray of nicotine is not available in Canada, but it has been used in Europe and in the United States.

What comes closest to the tobacco cigarette, in terms of delivering nicotine to the brain, is the electronic cigarette.

This is very important, because the smoker needs to have that kick to be satisfied and to remain in his comfort zone.

I don't know whether that answered all your questions.

November 6th, 2014 / 11:50 a.m.

Conservative

Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON

There was a question asked on whether or not e-cigarettes can be a gateway to smoking for young people, and Poland was mentioned. But I tell you, I just came back from Poland. I grew up there and I tried smoking regular cigarettes at a very young age. I didn't like it and therefore I never smoked, and nobody smoked at home. But I think many young people try this. If you do the statistics, probably you will see that young people try it. But I don't know what percentage get hooked on e-cigarettes.

What struck me—and this is not scientific, but this is what you see in the street—is that I saw a lot of young women smoking cigarettes while walking in the street there. Here, of course, we have made huge progress, with no smoking in public places. But in many countries in Europe, including Poland, they can still smoke in public places.

Another question I have is, should we regulate manufacturing of e-cigarettes, and if it should be regulated, how would you suggest it be regulated?

11:50 a.m.

Chest Physician, McGill University Health Centre, Montreal Chest Institute, As an Individual

Dr. Gaston Ostiguy

It should be regulated in terms that the concentration of nicotine is well marked on the bottle. You've heard stories that people were selling e-liquid pretending that it contained 15 milligrams or 18 milligrams of nicotine, while as a matter of fact it was almost down to zero.

If we don't regulate it, we're going to have an accident one of these days, because somebody is going to put some terrible stuff in it and put it on the market. It needs to be regulated; the smokers need to know that they are buying a good-quality product. Again, we'll have to keep pace with the new hardware of the electronic cigarette itself to make sure that it's functioning properly and also that people are using it properly. The manufacturing of the electronic cigarette is important, to ensure that it's good stuff and that the e-liquid sold in the shops is also good stuff.

11:55 a.m.

Conservative

The Chair Conservative Ben Lobb

Thank you very much.

Ms. Sellah, you have five minutes.

Go ahead.