Health Committee on Dec. 4th, 2014

[The Chair, Conservative, Ben Lobb]

We're going to get started here.

Thank you to our guests for being patient this morning. Unfortunately we have some more votes coming up before too long, but we want to make sure that we get your presentations on the record. If we have any time for questions, we'll make sure that we do ask those questions. If there is any follow-up, we'll make sure that we follow up with you.

Once again, thank you for taking time out of your day. Normally on committee we have the witnesses who are using technology go first while they're still connected and then we go to the ones who are here in person.

First off we'll go to Dr. Robert Strang from the Government of Nova Scotia.

Go ahead, sir.

[Dr. Robert Strang, Chief Public Health Officer, Department of Health Promotion and Wellness, Government of Nova Scotia]

Good morning to the committee. Thank you for the opportunity to speak today on electronic nicotine delivery systems, ENDS. I'll explain that term in a second.

I'm speaking in my role as the chief public health officer and chief medical officer of health for the Nova Scotia Department of Health and Wellness, as well as the recent past chair of the Council of Chief Medical Officers of Health.

For the committee, CCMOH consists of all the chief MOHs from the 13 provinces and territories, the national chief public health officer, senior officials from Health Canada, the first nations and Inuit health branch, Correctional Services Canada, Customs and Immigration Canada, and the Department of National Defence. As such, it represents senior government public health officials in Canada.

In 2013 the FPT deputy ministers of health asked CCMOH to provide their advice regarding the regulations on e-cigarettes. Today I'm going to speak to the position statement, which I know has been circulated to committee, that was developed by the provincial and territorial chief MOHs in response to that request. That position statement does represent the current consensus of FPT chief MOHs on the issue of electronic nicotine delivery systems.

To give a bit of background, e-cigarettes were developed in their current form in the early 2000s and have gained substantial market penetration globally. They are rapidly evolving as a product line, and alternative nicotine delivery systems are now appearing. That's the reason the language I will use today in our position statement is on the larger construct of ENDS and does not just use the term e-cigarettes.

It's important to acknowledge that some ENDS can also be sold for use with non nicotine-containing e-juice. There is also growing evidence that ENDS are increasingly being used for other substances, often illegal drugs such as marijuana.

The current legal status of e-cigarettes in Canada is such that electronic cigarettes with nicotine or that make health claims are regulated by the federal Food and Drugs Act, which means that they have to be authorized by Health Canada to be imported, advertised, or sold in Canada. To date, Health Canada has not given market authorization to any such products. E-cigarettes that don't have nicotine and don't make any health claims are regulated by the federal Canada Consumer Product Safety Act, which requires companies to ensure that the products they manufacture are safe.

Some points to make are that any assessment of policy options on ENDS must account for the need to acknowledge that we've made great strides in tobacco control in Canada with the greatest success being in the significant reduction in smoking rates for youth aged 15 to 19 years. But as new products such as ENDS emerge, it's important that we don't lose ground, particularly with the huge smoking segment.

Despite the current federal regulations, ENDS and e-juice-containing nicotine containers are readily available for purchase in all provinces and territories, both in stores and on the Internet. We can't ignore that reality. The lack of any regulations regarding product testing and labelling makes it extremely difficult to differentiate between those that contain nicotine and those that do not. There are also significant concerns around quality control and product safety.

We do also have to acknowledge that there has been a significant increase in the use of e-cigarettes, including by youth, since 2010.

The next point is that ENDS do present both risks and benefits at both the individual level and the population level, but there is no definitive scientific evidence in any of these areas at this time. However, waiting for more definitive evidence before taking action runs the very real risk of increasing overall and youth smoking rates, so essentially we can't wait to take some form of action.

To inform the development of the position statement, CCMOH held a virtual symposium in June 2014 to which we also invited members of the FPT Pan-Canadian Public Health Network Council, and the FPT Tobacco Control Liaison Committee. A summary of that symposium is an appendix to the position statement that was distributed to the committee. I won't take time to walk through that today.

The PT chief MOHs, in the summer of 2014, held follow-up discussions to discuss the information we had heard at the virtual symposium and developed our common position statement. That position statement was received by both the FPT deputy ministers and the ministers of health in August and September respectively in 2014.

Just to go through our position statement, this position statement is based on our collective expertise and experience in public health. The information was provided to us by five experts during the virtual symposium, as well as informed by discussions that we had among ourselves and by other discussions on ENDS products that many of us have been involved in.

We feel that given the current state of knowledge on ENDS, this position is an appropriate balance of allowing accessibility to these products as potential aids for cessation or reduction of tobacco use for existing tobacco users, while minimizing their potential to develop nicotine dependence and new tobacco users, as well as decrease the motivation for quitting for existing tobacco users.

I do need to clarify that our definition of ENDS in our policy includes both the devices as well as any accompanying e-juice containers. Our recommendations apply to all ENDS whether they contain nicotine or not.

Our recommendations that we made to provincial and territorial governments were to amend or develop legislation or regulations to first, make it illegal to sell ENDS to minors; second, make the point of sale display, advertising and promotion of ENDS illegal; and third, make it illegal to use ENDS in locations where tobacco smoking is currently prohibited.

Since we developed this position statement, Nova Scotia has passed legislation which brings all three of those recommendations into force as of May 31, 2015. Ontario currently has similar legislation in the legislative process.

For the federal government, our recommendation is, for the longer term, to develop a provincial-territorial engagement strategy to work together along with tobacco control experts to develop a new regulatory framework for ENDS.

We acknowledge that these products don't fit neatly as either a pharmaceutical or as a cessation product and ultimately we need a whole new regulatory approach to these products. However, given the time this process would require and the need for urgent regulatory action, we recommend in the short-term that ENDS should be considered as equivalent to cigarettes and regulated as such under existing federal legislation and regulations. That would mean advertising restrictions that are currently in place for tobacco products would apply to ENDS, that the standard labelling requirements that are required for tobacco products would apply for ENDS, and that the smoke-free requirements for federal workplaces and other federally controlled environments such as airports and airplanes would also apply to ENDS. We're also recommending that youth-oriented e-juice flavours should be banned.

I want to thank you for the opportunity to present today. I welcome any questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Dr. David McKeown, from Toronto Public Health.

[Dr. David McKeown, Medical Officer of Health, Toronto Public Health]

Good morning. Chair and members of the committee, thank you very much for the opportunity to speak with you today.

I am David McKeown. I am the medical officer of health for the City of Toronto. I believe you should also have access to a copy of our position statement on electronic cigarettes. In my presentation today I'm going to use the term “electronic cigarettes” or “e-cigarettes” as shorthand for all electronic nicotine delivery systems.

The City of Toronto as a local government has a long history of enacting progressive bylaws and policies to protect its residents from the adverse effects of tobacco. Toronto Public Health, a local public health agency, has also developed a number of evidence-informed positions for provincial and federal action on a number of ongoing or emerging tobacco control issues, including the one we're talking about today, e-cigarettes.

In August of this year the Toronto Board of Health endorsed Toronto Public Health's position statement on electronic cigarettes. That's the one that's been provided to you. This statement was based on our review of the available evidence on e-cigarette use, safety, health effects, and potential as a cessation aid, as well as our looking at actions in other jurisdictions and regulatory gaps at the federal, provincial, and municipal levels. Based on this review we identified a number of public health concerns about e-cigarette safety, its impact on youth smoking initiation, the potential to renormalize smoking behaviour, and to undermine existing tobacco control efforts. In the position statement, we identified a number of recommendations to address these concerns through federal, provincial, and even municipal action and regulation.

I was very pleased to see recently the introduction of Bill 45, the making healthier choices act, 2014, by the Ontario government, which includes measures to prohibit the sale and supply of e-cigarettes to anyone under the age of 19, to prohibit the use of e-cigarettes in all places where smoking of tobacco is currently prohibited under provincial legislation, to prohibit the sale of e-cigarettes in places where the sale of tobacco is prohibited, and to prohibit the display and promotion of e-cigarettes in places where e-cigarettes or tobacco products are sold. However, in addition to this legislation, there continue to be important opportunities to mitigate the public health concerns associated with e-cigarettes and their use in Canada.

Although e-cigarettes are almost certainly less harmful than traditional cigarettes, the long-term health effects of using e-cigarettes remain not fully known. However, when we looked at the science of this, existing, emerging evidence was nonetheless concerning. E-cigarette parts, liquid, and vapour may include variable levels of cancer-causing chemicals and harmful ingredients. Studies have also detected ultra-fine particles containing heavy metals in e-cigarette vapour and these particles have been found in levels similar to those found in conventional cigarette smoke. Because of their very small size, these metal particles can be deposited deep in the lungs which can increase the risk of respiratory disease. Their size also means that they can cross into the bloodstream and be deposited and absorbed into body tissues. Propylene glycol, which is a common base ingredient in e-liquid, is also a known respiratory irritant and, when heated and vaporized, it can form formaldehyde which is a cancer-causing compound.

Our review of evidence also noted that short-term studies have identified a number of negative health outcomes associated with inhalation of e-cigarette aerosol. These include airway, mouth, and throat irritation, decreased lung function, allergic reactions, and potential respiratory inflammation. The improper use of e-cigarettes, including accidental ingestion of e-liquids, has also accounted for a considerable increase in cases of nicotine poisoning and other injuries, especially among children, based on data in the United States. Although the harmful chemicals in second-hand vapour are found in relatively lower levels than in second-hand tobacco smoke, they may nonetheless cause a public health risk to non-users.

These safety concerns that we identified are compounded by gaps in the current regulation of e-cigarettes. E-cigarette parts, cartridges, and liquids are not subjected to the quality control and manufacturing standards or packaging and labelling requirements of traditional tobacco products. There is no assurance of safety for the user or for those exposed to second-hand vapour. Furthermore, as you're likely aware and as Dr. Strang has said, e-cigarettes are subject to different rules depending on whether or not they contain nicotine. Pursuant to Canada's Food and Drugs Act, e-cigarettes that do contain nicotine or make a health claim cannot currently be legally sold or marketed in Canada without prior approval.

It's my understanding that no such e-cigarettes have received federal authorization. Nevertheless, e-cigarettes with nicotine have substantially permeated the Canadian market. My staff and I are aware of many retailers that are currently openly selling nicotine-containing e-cigarettes here in Toronto. Studies in both the U.S. and Canada have also indicated that some e-cigarette cartridges that are labelled as being nicotine-free actually do contain nicotine. For these reasons, I recommend that the federal government subject e-cigarette devices, including cartridges and liquids, to strict consumer safety standards, including standards for manufacturing consistency, regulating the maximum quality or dosage of nicotine contained, stipulating labelling and reporting requirements, and requiring that e-liquid be sold in child-proof containers.

A chief public health concern related to e-cigarettes is the potential for the encouragement of youth smoking uptake. In 2013, about 15% of Ontario's youth in grades 9 to 12—about 100,000 students—reported they had used e-cigarettes, and nearly 4% of them had used nicotine-containing e-cigarettes. Although we lack data on whether or not e-cigarettes in practice act as a gateway to conventional tobacco use for youth, the current trends of use are concerning. In Canada as a whole, about 10% of non-smoking adolescents have tried e-cigarettes.

E-cigarettes could introduce adolescents to nicotine addiction and lead them to switch to cigarettes, which in some ways are a more effective form of nicotine delivery. Even if e-cigarette use in the end does not lead to youth tobacco use initiation, the use of e-cigarettes by youth, particularly of nicotine-containing e-cigarettes, is still of great concern. Overuse or high doses of nicotine can cause nicotine poisoning, and improper inhalation or physical handling of the e-liquid might also cause serious injuries. It is of great concern to see a new form of nicotine delivery system being marketed to youth without sufficient regulation. Nicotine has also been found to have potential negative impacts on adolescent brain development.

I'm also concerned about the potential of e-cigarette use to impair the process of de-normalizing smoking behaviour which has played such a key role in reducing tobacco use, and that they could undermine smoke-free legislation and controls across the country. E-cigarette use in places where smoking is prohibited may increase social exposure to smoking behaviour, which we know can have a powerful influence on the urge to smoke, particularly among children and youth, and also among current or former smokers who are trying to quit.

The recently proposed measures by the Ontario government to reduce youth access to e-cigarettes and restrict their use in places where smoking is prohibited are, I believe, an important step in addressing many of these concerns here in Ontario. I would encourage provincial governments across Canada to adopt similar measures to protect youth from the potential harms of e-cigarettes and prevent the re-normalization of smoking.

Federal regulation is also urgently needed to address the already mentioned safety and quality control concerns, and also e-cigarette promotion and advertising. We've been disturbed to see that e-cigarettes are marketed, particularly in the United States, in similar ways that cigarettes were promoted before most tobacco advertising and promotion was prohibited through federal tobacco legislation. This includes strategies such as free product offers, celebrity endorsements, overt lifestyle advertising, and attractive product packaging and flavours. This type of promotion influences the perceived acceptability of e-cigarette use and smoking, and I'm particularly concerned about its impact on youth.

Arguments that have been made against e-cigarette regulation have tended to focus on their potential use as tobacco cessation aids. E-cigarette safety and effectiveness for cessation have not been fully demonstrated, and they are not currently approved for this use here in Canada. However, none of the measures that I have recommended would prevent e-cigarette use for cessation should their safety and effectiveness be demonstrated through the existing approval process.

In closing, public health agencies across Canada, and increasingly internationally, agree that there is an urgent need to regulate e-cigarettes such that there is stronger protection of consumers, and particularly of youth, in ways that are very similar to the protection which is in effect for tobacco products. Federal legislation in particular should be amended to regulate all e-cigarettes, cartridges, and liquids to ensure manufacturing consistency and accurate labelling; to regulate the maximum quality or dosage of nicotine in e-cigarettes; to require that e-cigarette liquids are sold in child-proof bottles; and finally, to restrict e-cigarette advertising, marketing, and promotion in ways that are consistent with existing tobacco legislation.

Thanks for your attention. I'd be happy to answer any questions from the committee.

[The Chair, Conservative, Ben Lobb]

Thank you very much. You did a great job. That was 9 minutes and 58 seconds. That's Dr. Right On Time.

Next up, appearing live, is Dr. Jennifer Russell, from the Government of New Brunswick.

[Dr. Jennifer Russell, Acting Chief Medical Officer of Health, Department of Health, Government of New Brunswick]

Good morning, Mr. Chair;. Good morning, members of the committee. Good morning, colleagues Dr. Strang and Dr. McKeown.

My name is Dr. Jennifer Russell. I'm speaking as the acting chief medical officer of health for New Brunswick.

E-cigarettes pose a risk to the efforts and successes in tobacco control. Many e-cigarettes look like cigarettes, and their vapour looks like smoke. Years of work in tobacco control have led to many successes in reducing smoking rates and improving the health of our population. Although we are starting to see some studies and evidence on e-cigarettes, for the most part the science and evidence are still in early stages. We cannot wait for 100% of the evidence; we need to act urgently, as the risks are too high.

Some literature and surveys have indicated that youth believe e-cigarettes are healthier and less harmful than cigarettes. Youth feel that their use can be concealed and that they can use them everywhere, and they are accessible. Concerns include the negative impact of nicotine on brain development and the risk of addiction and of the initiation of use of other products, including tobacco-containing cigarettes.

The look and feel of these products pose a threat of the re-normalization of tobacco and risk undermining the work that has been done to date by tobacco control programs. They therefore should be treated as cigarettes in terms of the policies that promote the de-normalization of tobacco.

The New Brunswick Department of Health supports the recommendations provided by the provincial and territorial chief medical offices of health's position on e-cigarettes and electronic nicotine delivery systems. Over the past couple of years, the emerging trend of the sale and use of electronic cigarettes has public health professionals concerned about the potential health risks. There is an urgent need for preventative action.

One of the main concerns is the impact that e-cigarettes have on youth and young adults. ln the U.S.A., the use of e-cigarettes among youth doubled from 2011 to 2012. U.S. studies also indicate that youth's perception of e-cigarettes is that they are less harmful than cigarettes.

Marketing strategies in the U.S. industry are very similar to those decades ago of the tobacco industry in making the product very glamorous. ln addition, e-juices are available in a variety of flavours, such as bubble gum, cotton candy, Mountain Dew, coconut, etc., all of which are attractive to youth and young adults.

Studies have shown that youth who try e-cigarettes as a cessation aid continue to smoke regular cigarettes, and therefore there is dual use, use of both products. They have also shown that e-cigarettes seem to inhibit rather than promote cessation.

Public health practitioners are concerned about the substantial probability that this product will re-normalize tobacco and become a gateway for the use of other types of tobacco products and that the outcomes will be significantly negative to the overall health and addiction of the population and will have a detrimental impact on long-term chronic disease rates.

In New Brunswick, there is a platform commitment by the newly elected government, which has committed to expanding the Smoke-free Places Act to ban smoking in places frequented by children, including beaches, public parks, outdoor restaurant patios, and sports fields.

I feel this is a very important step in terms of protecting the rights of youth and children. Under the UN Convention on the Rights of the Child, it is the primary responsibility of governments at all levels to ensure the provision and protection of the children's convention rights, which include protection from harmful substances such as nicotine and tobacco products.

I would like also to echo the comments Dr. Strang made earlier with respect to the recommendations by the federal, territorial and provincial chief medical officers of health that, given the current state of knowledge about electronic nicotine delivery systems, we are trying to achieve a balance of allowing accessibility to these products as potential aids for cessation or tobacco use reduction for existing tobacco users while minimizing their potential to both develop nicotine dependence and new tobacco users and to decrease the motivation for cessation among existing tobacco users.

Youth are particularly vulnerable to developing nicotine dependence. My work with addiction services for six years looked at the risks for developing an addiction, which include experimenting with the substance prior to the age of 15, having adults in their lives who condone the use of the substance, and peer pressure. These are all things that are increased in the youth population, who are much more vulnerable and at much higher risk of developing dependence on substances such as nicotine.

In conclusion, again I would like to echo the comments from Dr. Strang regarding the position of the chief medical officers of health of the provinces and territories in that we recommend that advertising restrictions for tobacco products would apply to electronic nicotine delivery systems. Standard labelling requirements would be required such as they are for tobacco products. Smoke-free requirements for federal workplaces and other federally controlled environments such as airports and airplanes would also include the use of electronic nicotine delivery systems. The ban on flavoured cigarettes should also be extended to flavoured e-juice containers that are part of electronic nicotine delivery systems.

I would also recommend strict enforcement of these regulations and stiffer penalties for violators, and also to include childproof and tamper-proof regulations with respect to the manufacturing.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you.

The lights are flashing and the bells are ringing. I believe the votes are going to be taking place in about 20 minutes or so, which is just about the right amount of time to get back to the House of Commons.

I don't think there's any chance to have questions, so I will thank our medical professionals who have taken the time out of their schedule today to appear before committee. We aren't going to have a chance to ask you any questions, but after I adjourn the meeting, maybe the analysts could ask any outstanding questions they might have to help out with our report.

Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

We're obviously not going to get to committee business, so I'm not sure what is happening on Tuesday. I know there was some talk that maybe we didn't need to meet, but maybe we can meet for one hour just to deal with committee business.

[The Chair, Conservative, Ben Lobb]

Yes, we will have a meeting on Tuesday and we'll review parts of the pest control products act.

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

We haven't actually passed that, so that is a motion that's before us. It would have to be dealt with at committee business. We're fine to defer that to the new year. If we could reconvene on Tuesday just to deal with providing drafting instructions, that would constitute our last meeting for this year.

[The Chair, Conservative, Ben Lobb]

That's pretty good Christmas spirit heading into the holidays I would say.

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

Mr. Chair, just on a point of personal privilege, if I might, and it's completely out of order, I just wanted to say hello to Dr. David McKeown. I had the great pleasure of working with him when I was a regional councillor and I believe former councillor Adam Vaughan also had that pleasure while at the City of Toronto.

[The Chair, Conservative, Ben Lobb]

Mr. Vaughan, would you like to put one in there too?

[Adam Vaughan, Liberal, Trinity—Spadina, ON]

Yes, it's just to say hello to the doctor, and thanks for the good work and keep it up.

[The Chair, Conservative, Ben Lobb]

Well, that's good.

We'll see everybody back on Tuesday.

The meeting is adjourned.