Evidence of meeting #40 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.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
But what would be the purpose of someone using glycol in e-cigarettes?
Pharmacist, Canadian Pharmacists Association
It's the substance that the nicotine is dissolved in to help it be in a more dilute form so they're able to vaporize it and use it. It's similar to how you mix a drink and you put rum and Coke together. It's sort of the Coke to the nicotine. It's something that helps get it into your body.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
Is there any indication of a potential danger to people?
Pharmacist, Canadian Pharmacists Association
We don't know that yet. That's one of the questions we have, and it's one that's posed in any of the literature you read about it: what are some of the long-term effects of inhaling the vapour itself? It is a cleaner form of nicotine delivery compared to cigarette smoke, but we don't know if it is really safe.
We'd prefer to err on the side of caution at this point, to make sure that people aren't unduly exposed to things that may be found to be problematic down the road after millions of people have been using it for prolonged periods of time.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
Thank you very much.
The next question, through you, Mr. Chair, is for Mr. Khara.
You did say that people use e-cigarettes if they want to quit smoking. Now, from your practice, or maybe from some studies, how effective is it for smokers? Do they do it individually? Do they go to therapy that someone designs? How effective is that process?
Clinical Director, Smoking Cessation Clinic, Vancouver General Hospital
If the question is “how effective are electronic cigarettes as a cessation device?”, that's again a slightly complex answer, because there's a lot of anecdotal evidence. A lot of people will tell you that they have used electronic cigarettes to quit smoking. A lot of online surveys will also report that people are using electronic cigarettes to quit smoking, but if you look at trials that have compared electronic cigarettes to other evidence-based treatments to help people quit smoking, there's very little available.
Probably really only one randomized control trial of any rigour has been done, a New Zealand trial that suggested that electronic cigarettes were about as effective as a nicotine patch, but in that trial, both nicotine patches and electronic cigarettes were actually not very effective. But that's one trial and, for perspective, we can look at the thousands of trials that have shown that nicotine replacement therapies—patches, gum, and those kinds of treatments—are quite effective in doubling and maybe even almost trebling the likelihood of success.
I would suggest that there's an evidence gap even though there are some lower levels of evidence that electronic cigarettes can be helpful. The big thing that I think overlies all of this is that people like electronic cigarettes and people want to use electronic cigarettes. There is rapid growth in the use of these products, not in the way that nicotine replacement therapy is viewed, which is viewed with some lack of enthusiasm by people who are looking for an answer.
To answer your question, we don't really know how effective these devices are. That evidence is emerging.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
On the other hand, with the advertising campaign that's going on, people who never smoke, especially young people, will try e-cigarettes. Apparently a lot of them do try. Do you know what percentage would get addicted to nicotine?
Clinical Director, Smoking Cessation Clinic, Vancouver General Hospital
I'm sure Dr. Hammond will have a comment on that, but I would suggest that it's the missing piece. We don't know what the conversion rate is. I think some of the early evidence would suggest it's not very high. There is a lot of experimentation, but it doesn't seem like many people go on to become regular users. Maybe it's a little early to fully answer that question.
Associate Professor, School of Public Health and Health Systems, University of Waterloo, As an Individual
I think it's difficult to say, because we have many different types of products, and generations of products; but the answer is, to date, that conversion rate is very low. We see a very small fraction of young people who try e-cigarettes go on to use them with any frequency. That is not to say that these products can't be addictive. The design of these things is rapidly changing, and the elements that may make them an effective replacement, substitute, or cessation product for smokers, may well make them more appealing for youth to try in the long term. It's not to minimize the risk at all. It's just that we haven't seen much conversion to date.
November 4th, 2014 / 12:15 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Again, thank you for waiting this morning.
I guess many of us are running out of questions, at least I am. Everyone we've listened to has been saying the same things. As Dr. Khara just said, there is a lack of evidence with regard to the ability of e-cigarettes to be effective as a smoking cessation tool. Another point is that we really need to look at the nicotine liquid in the hands of small children. At the end of the day, we've heard that everyone is saying, “Look, in the vacuum in which we now exist in Canada, let us at least regulate for safety's sake“. I'm hearing that over and over and over.
What I would like to focus on however, is what one of the pieces of regulation would look like. Obviously, there would be measures for minors, keeping it out of the hands of children, etc. The point I wanted to talk about is what Ms. Davies touched on, which is potency. Should there be a limit to potency of the nicotine in the liquid?
I would also like to know if you think flavouring in nicotine liquid should be banned, because it really is an incentive for young people to like it and to want to use it, even if regulations are put in place to prevent them from getting it.
The potency is the piece I am a little concerned about. Why? We know that cancer and other harms, such as all of the tar and benzo[a]pyrene etc., are associated with cigarettes. Nicotine is still a very addictive substance. I am told that nicotine is as addictive as heroin, or that heroin is as addictive as nicotine. The two of them are on a par. The question of potency then becomes really important.
I just wanted to hear you expand a little bit on potency.
President, Canadian Association of Poison Control Centres
My point of view is very particular on this subject. Being a medical toxicologist—and Canadian poison centres are handling acute exposures—what I am concerned about is the potential for liquid nicotine to cause harm, especially in children, because children under six years of age have a smaller body weight, and they are also very curious by nature.
What is it that they actually overdose on? They overdose on whatever they find in their environment, especially at home.
Tobacco products have been around for a long time, but everyone will realize that it is much more difficult for children to be exposed to a big amount of nicotine by chewing on conventional cigarettes. It's very likely they are not going to be able to chew more than just a little piece. It's completely different with liquid nicotine, which will be absorbed very quickly. On top of that, if flavourings such as cherry or grape are added, we create a situation with a toxin that's very potent, a liquid preparation that could be absorbed through the skin or the gastrointestinal tract very rapidly, and a flavouring that makes the substance attractive to children. We might be seeing the stars align for a big catastrophe and the perfect storm to happen in the future.
That is my position.
Associate Professor, School of Public Health and Health Systems, University of Waterloo, As an Individual
You are absolutely right when you say that nicotine is highly addictive, but that's a function of the mode of delivery. When you deliver nicotine through the patch or the gum, so transdermally or orally, it's not very addictive at all. In fact, it has a very low abuse liability, and, as Dr. Khara said, most people don't want to use it. We have to encourage smokers to keep using it for the minimum amount of time.
E-cigarettes and vapour will likely fall somewhere in between. It's unlikely to be as addictive as smoke because it's all about the rate of delivery, the rate at which it gets into your bloodstream. Vaporized nicotine will fall somewhere between smoke and mouth or skin.
On the issue of concentration, you may know that the European Union has set a maximum concentration for nicotine in e-cigarettes. I would urge this committee to look at what's happened in the European Union and the U.K. because it's not as if a country has not tried to elaborate this regulatory framework.
Having said that, it's the user who controls the dose. You can have half the concentration and take twice the puffs or the inhalation. You want to make sure that it's not overly toxic per dose, but ultimately it might be a bit of a fool's errand.
On your last point about flavouring, real harm reduction advocates suggest that you keep the flavours in because that makes smokers want to use it. I think it would be more conservative and probably prudent to eliminate the cotton candy flavours, the cherry flavours. My opinion is that if an adult smoker is genuinely using this to help him quit, they don't necessarily need cotton candy flavouring to promote this product.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
We're up to five minutes now.
Next up I have Mr. Young on my list.
Conservative
Terence Young Conservative Oakville, ON
Thank you, Chair. I'd like to share my time with Dr. Lunney, if that's okay.
With what we've heard so far, the best endorsement that we've heard for e-cigarettes was today. We heard that they're basically better than death. That's the best endorsement we've heard so far. I wanted to tell you that because you weren't at our other meetings. It's not a great endorsement.
Dr. Laliberté, I would like to follow up your comment on the poisonous effects of nicotine. You said it was originally marketed as an insecticide.
My question is on whether a curious five-year-old or six-year-old could open up one of these things and drink the liquid nicotine and cause death.
President, Canadian Association of Poison Control Centres
Yes. Clearly it's just a matter of time.
Most medical toxicologists were not in practice in the years when nicotine sulphate was actually used as an insecticide, but the older medical toxicology literature has many case reports of children dying after exposures to liquid nicotine. Of course, the concentration was very different. It used to be anywhere from between 24% up to 40%. We're down by a factor of about 10 with the preparations that are available now.
It's just a matter of volume. If a child ingests enough liquid nicotine, that child is at risk of dying and will likely die very quickly. Anything I can do to help that child.... But short of supportive treatment, there's really nothing I can do.
Conservative
President, Canadian Association of Poison Control Centres
—might die before reaching the hospital. There would be no possibility for me to clean his gastrointestinal tract. Supportive treatment is the same. We have no known good antidotes for nicotine.
That's a cause for concern.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
Thanks, Terence.
The time is so short, but I will try to get a couple of questions in here.
We talked briefly about propylene glycol. The boiling point I understand is 188 degrees centigrade, but it has a flashpoint; at over 109 degrees, the vapour can be ignited. Propylene glycol is in all kinds of products, low-risk antifreeze, for example.
You can already see online how to convert your dry marijuana to be able to vape it this way. Kids can be using this odour-free form and toking up in front of their parents without the parents even knowing they're getting the hit of marijuana inhaled in this way—vaped.
But it's the whole list.... I want to ask your opinion on this because it's poison control.
Any medication out of a parents' cupboard could be ground up, powdered, similarly mixed with propylene glycol, and inhaled this way.
For poison control, are we not naive to think it will only be nicotine that we need to be concerned about with these products? Are any of you at the table concerned about that, and our pharmacy friend as well?
President, Canadian Association of Poison Control Centres
I'm going to make a very short comment on that.
The potential toxicity, acute toxicity, of nicotine versus the toxicity of propylene glycol is completely different. What we're concerned about right now is the nicotine sulphate.
I'm not saying that it's impossible for young people, teenagers or young adults, to find creative ways of misusing the propylene glycol. Believe me, this is something that I deal with on a daily basis. They always seem to find a new way to get into trouble. However, if you compare the two, I mean, clearly the danger here is nicotine sulphate.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
No, I'm talking about vaporizing anything here, Dr. Khara, and then combusting it. Who knows what breakdown products of any chemical you're likely to end up with?
Clinical Director, Smoking Cessation Clinic, Vancouver General Hospital
I don't believe there's any published evidence, at this point, about other substances being vaporized through the traditional electronic cigarette, but there's certainly lots of anecdotes about marijuana oil. So, you may well be right. This may well become a vehicle for other things, and we may have other considerations at that point.
But just to answer the propylene glycol issue, it's certainly used in lots of things, and the proponents of these cigarettes would say that we use it in lots of things and it's harmless. But nobody actually, I would suggest, knows the answer to what chronic inhalation of propylene glycol will mean. We'll get that answer in about 10 years, or whatever. Right?
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
Right.
So, that's a concern. Also, online, here, there's how to smoke weed in your e-cigarette, how to prepare it with the propylene glycol, and how to make your own mix very quickly. So, I think we're naive if we think it's only nicotine we need to be concerned about with this inhalation delivery mechanism. We know with medication, delivery mechanism makes a difference.
Pharmacist, Canadian Pharmacists Association
I think I would agree with Dr. Khara. It's something we need to be aware of and watch, but the nicotine is the bigger issue here in a lot of ways. We don't know what the effects are. So let's design whatever system we're going to design so that we can find out what the problems are that may be created by the inhalation of these products.