Front Burner - Canada’s rules on e-cigarettes based on ‘unproven hypothesis’

Episode Date: December 2, 2019

There are fewer restrictions on vaping devices in Canada than on tobacco, cannabis or even alcohol. Health Canada made e-cigarettes widely accessible based on an understanding that they could be used as a smoking cessation tool. Now, Canada is investigating almost a dozen possible or confirmed cases of vaping-related lung disease and the U.S. is tallying up thousands of lung injuries and over 40 deaths.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hello, I'm Jamie Poisson. There are fewer restrictions on e-cigarettes in Canada than on tobacco, cannabis, or even alcohol. And that actually makes quite a bit of sense if you think of them as just a tool for quitting smoking, which is how a lot of people saw them.

But consider the recent flurry of worrying news. Canada is investigating almost a dozen possible or confirmed cases of vaping-related lung disease. Quebec is launching a task force to fight vaping, especially among teenagers. Health Canada has made e-cigarettes widely available across Canada, but all of this is raising the question of whether it's aiding or injuring public health. Today on FrontBurner, we talked to the CBC's medical sciences correspondent Kelly Crowe about how Health Canada flung the door wide open to e-cigarettes without, experts say, any definitive evidence that it would even help people quit smoking. that it would even help people quit smoking.

Kelly, hi. Hi. Thanks so much for being here. My pleasure. So I want to get a sense of the scope of this problem. I think we've all heard about the dramatic number of lung injuries attributed to vaping in the United States, over 2,000 now. What's the situation like here in Canada?

Well, the most recent statistics suggest that there's been an increasing surge in youth and young adult use of vaping products. So the most recent statistics, and we're just waiting for even more recent statistics coming out in the next couple of weeks, show that about a quarter of Canadian high school students are using vaping products. Okay. And these statistics follow a lot of anecdotal evidence. We've been hearing teachers saying the kids are smoking underneath their T-shirts in class. And we've got schools reporting taking the doors off bathrooms. I've heard students slipping on the cartridges that have been dropped in the high school stairwells. And so lots of young people vaping, we know.

And what about the illnesses here? What do we know about confirmed cases? Well, the illnesses, that's complicating the story a little bit because it's still not clear what precisely is causing these illnesses. We did have one case in London where the young man ended up having what they call popcorn lung. The 17-year-old boy from London, Ontario, was brought here earlier this year to the Lung Transplant Centre at Toronto General Hospital. Doctors say he was near death.

Which is an industrial disease that was observed years ago in workers who worked with this particular flavouring ingredient. Right. It doesn't mean like your lung looks like popcorn, which I guess intuitively is what I thought it might have been. But that workers were exposed to this chemical in microwave popcorn, and this is what made it taste like it's popcorn flavor. Yeah. So presumably that flavor was in a vaping device. But that's a different manifestation than some of the, they call it the EVALI diseases. And speaking of these mysterious diseases, I think we've got four confirmed cases here in Canada, three in Quebec, one in Ontario. Right. But now there's also emerging signals about other possible health impacts on lung tissue more generally or affecting heart disease. I think it's important

not to think of the vaping sort of situation right now only in terms of this outbreak of these mysterious diseases, but in terms of the emerging signals from all kinds of different places that perhaps widespread population health exposure might not be a net public health gain. You mentioned that a lot of young people are using e-cigarettes. What do we know about the population as a whole? Well, the industry is not required to report statistics to the government. So I don't think we really have any measurement of what the volume of sales are or what the percentage of people who smoke are using.

Statistics from other jurisdictions are suggesting smokers have started using vaping products, but not exclusively. So the real question is going to be, do smokers start vaping and stop smoking? Because the only way that this is a health benefit is if it eliminates combustible cigarettes. Right. That's the part of the equation that is not known and it hasn't been known. In fact, the signal that's emerging now is that it's not working very well. It hasn't necessarily moved people from smoking to vaping. Well, I think it's moved people from smoking to add vaping to their suite of nicotine devices. But whether it's achieved the goal that the public health officials had imagined, which is that we were going to move to this post-cigarette

utopian tobacco-free future, we're not there yet. And in fact, there's no real measurement that we're even getting there. The unintended consequence has been exposing new users to a nicotine habit. And some of the industry documents that I've seen in the presentations that they make to their investors, and this is all publicly available information, you see the industry showing that 60% or so of their vapers are actually new users. So these are not smokers coming over to vaping. They're people coming into the market.

They're just picking up vaping in the first place. Yes. So today I'm hoping that you can help me understand how vaping really proliferated here. Like, how did we get to this point? And to do that, I think we need to talk about how it's been regulated. You've sort of alluded to this. E-cigarettes have been around for a decade now. And, you know, early on, can we talk about what Health Canada's initial stance was and how it's evolved over time?

Can we talk about what Health Canada's initial stance was and how it's evolved over time? So the interesting thing when we went back and took a look at how we got here was that the first instincts of the public health regulators in Canada and the U.S. was to slam the door shut. Okay. These devices, I guess it's important to start out saying, they sort of slipped onto the market. A couple of small companies began importing a Chinese product and it began to be sort of out there, internet-based sales and that sort of thing. And at that point, Health Canada's instincts were that we don't know what these are, we don't know what's in them. So they issued a strongly worded warning saying to Canadians, don't use them because we don't know what's in them or what they're doing. Okay, so they were like illegal here. And they were, well, nicotine-based vaping devices were illegal.

Okay. The other ones would just be like flavoring or... I suppose, I know you can put cannabis in them as well. Well, cannabis was illegal at the time too. So they remained illegal until just May 2018. But getting to 2018, Health Canada had to try to figure out what to do about these devices. And there was a strange kind of role reversal in the marketing because it wasn't the industry that was out there saying these will help you quit smoking. And in fact, if they had said

that, they probably would have had to get approval as a medical device. So the standards would have been much higher. They would have had to produce animal tests. They would have had to produce clinical trials. They would have had to get a special approval. So they didn't do that. What happened was they simply made this product available, highlighted the fact that this gave smokers an alternative, and the public health officials are the ones who were running with this idea that this could be the secret to finally getting the last 15% of Canadians who keep on smoking to quit. And what evidence did they have at the time that this was safe,

that this was a good idea? They didn't have any. So why did they do that? Well, it made sense. I mean, the point that I tried to make in my reporting on this is that we never stopped and said, what is a vaping device on its own? It's a cocktail of addictive nicotine and other compounds that have never before been inhaled into the lungs that are suddenly out there and being used. Is that a good idea?

Right. The conversation didn't really start there. It started always as a relative comparison. How are they compared to combustible cigarettes? And they are better than combustible cigarettes or so everybody believes. It seems so obvious. Now, in an evidence-based situation, we don't have the evidence of that even now in terms of a head-for-head comparison, in terms of long-term use. I argue that the industry got a bit of a free pass because they didn't have to prove that these devices were safe or that they worked for smoking cessation. The public health officials argued among themselves. Well, there

was debate. I talked to Dr. Charlotte Pissinger, who's a Danish tobacco control physician, I talked to Dr. Charlotte Pissinger, who's a Danish tobacco control physician, who was one of the early voices, warning voices, saying, I'm not sure about these. And even as Public Health England was coming out with a statement saying, these are 95% safer than cigarettes, she was doing a systematic review, the first one, and she said, I'm not so sure. And she updated that again a couple of years later and said, actually, the signal for harms is growing. But she said she felt alone. Maybe in Denmark it was because it wasn't considered a problem. There were only a few

percentage of the population that were vaping at that time. And we had no registration on vaping in youth. She was up against very powerful, very prominent tobacco control experts. Most things, nicotine replacement products like patches, gum, nicotine inhalers, tobacco counseling, still only works about 20% of the time. And usually people have to quit many, many times before they finally are successful. So when this came along, it did seem like the magic bullet. And so when Health Canada rolled out its regulations just last year and e-cigarettes became legal, what was the approach that they took? Well, they tried to strike a balance, but the balance was in the direction of making the vaping products as widely accessible as they could.

So that meant leaving flavors in because they felt that smokers might be more inclined to use them. As it turns out, smokers actually prefer the taste of tobacco. So there's some suggestion that actually this doesn't appeal to smokers after all. But in any case, the thinking was, how do we make these as accessible as possible and still try to keep kids from using them? That was basically the balance they tried to strike. But instead, they didn't restrict them to adult-only locations. They allowed them to be sold pretty much anywhere. They did try to put restrictions on no advertising that would appeal to kids, no cartoon characters, no candy flavors that have candy names. You can use the flavor, but you can't call it a candy name, lollipop.

And after these regulations came in, did we see a greater uptick in use? When the new law passed in May 2018, that's the first time that it was legal to sell a nicotine-based vaping device. That just so happened to time precisely with a brand new type of vaping device that had been made by Juul. And now since other tobacco companies have come along, it was a nicotine salt-based device that delivered a strong hit of nicotine, less irritating to the throat, and in a cool, slim, USB-style device that kids could slip in their pockets and use when the teacher wasn't looking. So Juul came onto the market in September 2018, just a few months after the new law. And then that changed everything. That's when teachers started seeing

these in the classroom and doors came off the bathrooms and we started doing stories about this youth uptake. So everything changed at that point. And speaking of Juul, you know, I understand that big tobacco is playing a role in all of this as well, something I didn't know. Well, that has evolved. A third of the company has been purchased by Altria, one of the big tobacco giants. And the other tobacco companies are all in the vaping business now too. Big tobacco is now big vape. And so what role is big tobacco playing vis-a-vis the government? Well, it's a weird situation if you think pariah when it came to public health policy, to have big tobacco back at the policy table,

consulting with government is unfathomable. It's definitely, I think no one would have predicted this. Right. We've learned that Health Canada, for example, wants to come up with a series of health claims that the tobacco companies could put on the vaping products. All of the tobacco claims would have something to do with the relationship to cigarette smoking, as in safer than cigarette smoking or that sort of thing. When you think about tobacco, cigarettes have warnings on them.

So this is going from, I do not smoke this because it could kill you to, well, you could smoke this because it's better than that, is a very unusual turn, I think, in the marketing. And some academics who've watched the tobacco industry move into the vaping industry think that that might be part of the objective, which is to get back at the policy table and have some role in shaping the regulations. And right, I'm sure many experts you're talking to are saying that big tobacco possibly has a conflict of interest here, obviously. I think this is what's the undercurrent to this story is, you know, how sincere is an industry whose still primary product is cigarette smoking and cigarette sales? How sincere are they in their stated goal of seeing a future where nobody's using their major product.

Right. So I think that is what is causing some of the public health experts to have second thoughts, especially now that they see so much youth uptake. If this was targeted only to smokers and if it was a sort of a finely tuned policy, that would be different. But this is a population-wide exposure where 80% of the population doesn't smoke and we are seeing evidence that new nicotine users are developing this habit. That is one of the most concerning things about the statistics of youth uptake is that these are kids who weren't smoking and probably wouldn't have smoked. In the Dragon's Den, a simple pitch can lead to a life-changing connection.

Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization. Empowering Canada's entrepreneurs through angel investment and industry connections. Everything you've said here feels incredibly alarming. But I imagine there are still lots of people who will say, one, cigarettes are much more dangerous than vaping. All the information we have shows this. Two, vaping has helped people stop smoking. In theory. Okay, maybe you can pick up on that for me. And three,

the last thing is that we should be making these available to people in a legal way, because if not, then they'll use illegal products, and those could be even more dangerous. Well, I think everybody supports the idea of regulation. And I think the question is, how are they regulated and how do you keep the product targeted at the smoker who wants to quit, who will use this for that purpose and away from being encouraged for everybody else to use? Now, David Hammond, University of Waterloo researcher who's been tracking the statistics on youth vaping, says... So we're failing both target markets.

We're not protecting kids, and we're not actually doing a good job getting the products in the hands of people who could benefit, which is adult smokers, to quit. What does the future market hold? It can't look like it is today. And as we sit now, right now, the regulations that would, you know, tighten up the marketplace have not been put into place yet. For example, listing ingredients or forced sort of standardization.

But I think that is the goal. So I think that the question now for a lot of the people who were first promoting or at least hopeful for these products is we have to dial it back, close the door. Now you see the provinces coming up with stricter laws to control where they're sold and the age that people can use them and that sort of thing. Canada's new health minister says her agency is monitoring the effects of vaping on kids and may ban certain flavors. From my perspective, I'll be speaking with stakeholders, I'll be speaking with my colleagues about what stronger actions we can take to protect young people from the effects of vaping, but also the effects of advertising. The question that interested us as we worked on this story was how did we get here and what was this unusual public health position where the government felt it had to try to make this

available without the evidence that actually it was going to do what they thought. How do we get to a place where the doors were this wide open? Right. Fair for me to say that many of the experts you talk to think that the current rules are not nearly enough. No, there definitely, I think, is a sense that we need a course correction. Okay. And you said in theory, when I made the point that vaping has actually helped people stop smoking, what did you mean by that? Well, that's the big question. Is it actually working in the way that it's intended? That's the piece of the puzzle. I mean, I'm waiting to see is when we have some really reliable data about how effective this is at getting smokers to quit.

That evidence isn't there. And the other interesting part of the evidence that we do have is that there's no projected drop in cigarette sales when you look at the industry forecasts. Really? They're forecasting robust cigarette sales and vaping is an additional product. So I think that one of the big questions will be, is this going to have the intended effect over a long term? Or are we seeing an additional nicotine use that essentially this may not even be accomplishing its goal in the first place? And it may be creating this entirely new problem. Right.

Okay, Kelly Crowe, thank you so much. Thank you. So off the top of our conversation, you heard Kelly mention that the cause of these vaping-related lung injuries was still undetermined. In the U.S., though, new evidence is strengthening the case for a few possibilities. The Centers for Disease Control have been performing tests on illegal THC vaping products and lung fluid belonging to people in these cases. And a large percentage of them are showing traces of a common substance, synthetic vitamin E oil or vitamin E acetate.

So we'll continue to follow the story as it develops. That's all for today, though. I'm Jamie Poisson. Thanks for listening to FrontBurner. See you tomorrow. For more CBC Podcasts, go to cbc.ca slash podcasts.