Update on Vaping in Canada
(Jan2022-April 2023)
Lots of fine words, less action
First, the good news:
In a December 2022 press release, The Honourable Carolyn Bennett, Minister of Mental Health and Addiction and Associate Minister of Health, said:
“Vaping products offer the 3.8 million Canadians who smoke a less harmful source of nicotine than tobacco products, and do help people to stop smoking.”
Canada’s Tobacco Strategy
Canada seems to have a good plan for dealing with tobacco use.
“Each year, approximately 48,000 Canadians die from a tobacco-related disease. Canada’s Tobacco Strategy (CTS) is the current federal strategy to address tobacco use in Canada and is designed to help achieve the target of less than 5% tobacco use by 2035.”
“The Tobacco and Vaping Products Act was passed on May 23, 2018. It makes it legal for adults to buy vaping products that contain nicotine, as a less harmful option than smoking.”
The CTS website also notes that giving people who smoke access to less harmful options than cigarettes will “help reduce their health risks and possibly save lives.”
Giving people who smoke access to less harmful options than cigarettes will help reduce their health risks and possibly save lives.
Canada’s Tobacco Strategy
The main themes of Canada’s Tobacco Strategy include helping Canadians to quit tobacco by supporting improved services and resources to help people quit smoking and giving information on and access to less harmful sources of nicotine.
The strategy is also aimed at protecting youth and non-tobacco users from nicotine addiction.
This all sounds very good. The implementation may well be another issue. In September 2018, Health Canada started to work on a set of agreed statements that vape store owners could use when talking about vaping to their customers, but the final list has still not been approved. Currently, vape store staff cannot tell potential customers that vaping is safer than smoking, or that vaping can help people to quit. This is a total failure with respect to “giving information on less harmful sources of nicotine”.
Report of the First Legislative Review of the Tobacco and Vaping Products Act (TVPA) – Dec 2022
This long-awaited report was mandated by the TVPA. It was published shortly after Physicians for a Smoke-Free Canada started a legal action to force its publication.
It concentrated on the issue of youth vaping and did not say much about the use of vaping as an alternative for people who smoke.
The report acknowledges that “the majority of adults who currently smoke are not aware that vaping products are less harmful than using tobacco products. A recent survey conducted in 2021 showed that only 17 percent of adults 20 and over who smoke and do not vape understood that vaping is less harmful than smoking cigarettes”. “Work could be undertaken to communicate the relative risk of smoking, in comparison to vaping, to people who smoke. These measures could include assessing the merits of developing relative risk statements and requiring the tobacco industry to use prescribed messages in cigarette packages and updating website materials. Such information could assist Canadians in making informed choices about their health.” Note the use of the word “could” instead of “should” or “must.”
“The majority of adults who currently smoke are not aware that vaping products are less harmful than using tobacco products”
First Legislative Review of the Tobacco and Vaping Products Act
When making comparisons with other countries, the comparators used were the UK, the USA and Australia, but not New Zealand.
Manufacturers of medical NRT “recommended a shift away from the current market where vaping products can be sold as either consumer products or therapeutic products. They suggested solely therapeutic regime, which would require all vaping products to be evaluated for safety, quality, and efficacy under the FDA and receive approval by Health Canada.” This is no surprise as manufacturers of medical NRT are losing market share as vaping is being used by many people who smoke as an alternative to NRT.
“While vaping products are not harmless, there is also strong evidence to suggest that for people who smoke, completely switching to vaping is a source of nicotine that is less harmful than smoking cigarettes. A recent systematic review examined the effectiveness of e-cigarettes; it found that vaping nicotine products do help people to stop smoking for at least six months and does so at a higher rate than traditional NRT use.”
“Some members of the general public and the majority of industry submissions asked that regulations be established to set out a selection of authorized statements about the relative risks of vaping products. Their request was supported by some academics. However, some industry stakeholders believe that they should not be limited to the use of only authorized statements and consequently they asked for broader permissions in communicating with consumers.” “Work could be undertaken to assess the merits of approved relative risk statements that would compare the health effects of vaping use for individuals who smoked and completely switched, with those associated with tobacco product use, for which regulatory authority currently exists in the TVPA.” This has been underway since September 2018, and no statements have yet been approved. Also, again notice the use of the word “could,” not “should” or “must.”
“Finally, many vaping industry stakeholders and some provinces recommended the inclusion of a mandatory leaflet in cigarettes packages that would explain the health benefits of vaping and other NRT products as a way to promote harm reduction to those who smoke.” This simple idea has been discussed for years but never implemented.
The Health Canada website – Revised Feb 2023
“The 2021 Evaluation of the Health Portfolio Tobacco and Vaping Activities, recommended that vaping-related information on the Government of Canada’s website be updated to reflect the most up-to-date science and public health advice on the health hazards of vaping and potential benefits vaping may offer in helping people who smoke.” This seems to have happened in February 2023, and the Health Canada website takes a fairly reasonable and fact-based approach to vaping.
It gives an accurate description of vaping equipment and vape juice. It states clearly that “Vaping products do not contain tobacco” and” nicotine itself is not known to cause cancer.”
It offers sensible safety advice and makes fair comparisons with cigarette use. “Using vaping products with higher power and temperature settings can produce greater numbers and amounts of potentially harmful chemicals. Some metal contaminants (e.g. nickel, chromium, tin, aluminum) may also get into the aerosol as the metal heating element ages. Some of these chemicals and metals are known to cause cancer, however, the levels found in vaping aerosol are significantly lower than those found in cigarette smoke.
(https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping.html )
The section on vaping risks appropriately dismisses popcorn lung and EVALI.
“Vaping products do not contain tobacco.
The Health Canada website
Nicotine itself is not known to cause cancer.
Vaping is not known to cause Popcorn lung”
“Vaping is not known to cause Popcorn lung.” “While once common in vaping products, researchers at Health Canada have in recent years found diacetyl in only 2 samples out of more than 800 vaping liquids available in Canada . To date, there have been no confirmed cases of popcorn lung disease as a result of vaping in Canada.”
On EVALI, it states that “evidence from the US suggests a link to unregulated tetrahydrocannabinol (THC)-containing vaping products that contained additives, such as Vitamin E acetate.” “Products obtained from illegal or unregulated sources may be contaminated with adulterants like Vitamin E acetate, which is not allowed in regulated products because of the harm it can pose when inhaled.”
(https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/risks.html )
The section on vaping to quit smoking is fair and balanced. It begins:
“A number of Canadians are trying to quit smoking by vaping nicotine, and have said it has helped. While the science is evolving, evidence suggests that vaping nicotine (using e-cigarettes), can help adults quit smoking. If you’ve tried approved methods to quit and are still smoking, switching completely to vaping nicotine is less harmful than continuing to smoke.”
After discussing other options, it then says:
“Though vaping products are relatively new and research into their long-term effects is ongoing, researchers have already established that switching completely to vaping nicotine is less harmful than continuing to smoke.”
“The best available evidence indicates that adults who smoke, who then switch completely to vaping:
- Immediately reduce their exposure to the harmful chemicals found in cigarette smoke;
- See general health improvements in the short term as a result of no longer smoking cigarettes;
- May be more likely to quit smoking than those who use nicotine replacement therapy (NRT) or counselling to quit;
- Do not currently report serious unwanted effects while using vaping products to quit;
- May have a higher startup cost but save money in the long run (cost per equivalent puff).
“If you’ve tried approved methods to quit and are still smoking, switching completely to vaping nicotine is less harmful than continuing to smoke.”
The Health Canada website
It does note that: “To date, vaping products have not been approved in Canada under the FDA, which means these products are not available by prescription from your health care provider.” Some tobacco companies claim to be interested in transitioning away from combustible tobacco (e.g. Rothmans Benson and Hedges, https://www.unsmoke.ca/). If they are serious about this, they should make a vape that can be approved in Canada.
It concludes with advice to quit smoking entirely and to continue vaping until the risk of relapse to smoking has disappeared: “Dual use means that you are not completely avoiding the risks of harms of smoking cigarettes. Smoking any amount of cigarettes is harmful.” “Stop smoking all cigarettes as soon as possible. Once you vape exclusively, quitting vapes will further reduce risks to your health. Only quit vaping when you are confident that you will not relapse to smoking.”
(https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/quit-smoking.html)
I give Health Canada an “A” for this. The information provided is simple, direct, evidence-based and actionable. The only problem is that I do not think that enough Canadians read the Health Canada website. Putting accurate information on the web is an excellent start, but now they need to get that information out to everyone who smokes, to their friends and relatives, and to their healthcare providers.
Health Canada supports the “SmokeFree Curious” website – Jan 2022
Health Canada supported several anti-smoking organizations to create a “Smoke-Free Curious” website to encourage people who smoke to consider quitting. The only method of quitting smoking that was discussed was medical NRT. The site was sponsored by Johnson and Johnson, who provided free NRT to readers of the website. “This Combination Therapy Trial offer would not be possible without sponsorship from McNeil Consumer Healthcare, a division of Johnson & Johnson Inc., makers of NICODERM® and NICORETTE® . We thank them for their support.”
In effect, Health Canada helped pay for a website advertising Johnson and Johnson’s NRT products that did not offer any information about other ways to quit smoking.
WHO rejects Canadian plant-based vaccine because of links with the tobacco industry – March 2022
A Covid vaccine was developed and manufactured in Canada, approved for use by Health Canada but banned by the WHO.
Medicago produced Covifenz, the world’s first plant-based vaccine, with funding from a tobacco company. Unlike the mRNA vaccines, it does not require refrigeration, a huge advantage for areas where the electrical supply is unreliable.
Medicago’s request for an emergency-use listing – aimed at expediting the availability of vaccines around the world during public-health emergencies – was denied by the WHO “because of the linkage with the tobacco industry and WHO’s strict policy on not engaging with companies that promote tobacco.”
An emergency-use listing is required in order for vaccines to be used by COVAX, a global initiative to share vaccines with low- and middle-income countries.
Once again, the WHO puts politics above public health.
https://www.theglobeandmail.com/canada/article-who-medicago-covid-19-vaccine/
Ottawa Model for Smoking Cessation Conference – Jan 2023
The conference included many interesting subjects:
- THE CHANGING LANDSCAPE OF NICOTINE PRODUCTS – A FIRESIDE CHAT | Cynthia Callard, Physicians for a Smoke-Free Canada, Moderated By: Dr. Andrew Pipe *Learning objectives: Summarize the evolution of nicotine products over the past several years, as well as corresponding developments in approaches to smoking cessation.
- WHAT DO OUR PATIENTS WANT FROM QUIT SMOKING EXPERTS? | Panel of current and former patients. *Learning objectives: Determine the challenges people who smoke face when considering cessation and explore novel opportunities for healthcare professionals to assist.
- MISINFORMATION AND DISINFORMATION ON SMOKING/CANNABIS/VAPING: 5 SMOKING MYTHS THAT YOU WISH YOU COULD KILL OFF | Dr. Andrew Pipe *Learning objectives: Identify common smoking myths and explore ways to address them.
I registered many months in advance of the event, but for the second year I was banned on the night before the conference because of my ties to tobacco and vaping. The timing just seems rude. The action is counter-productive. I am a physician and a scientist: if you present me with new data or a novel argument I will listen and change my opinion when appropriate. If you lie to me, I will call you out. That is how science is supposed to work: A free and frank exchange of ideas between people who hold different opinions that checks that the data is reliable and then produces the best possible hypothesis to explain it. Science needs dissent, not affirmation.
A pharmacist who has developed an approved CME course on smoking cessation for pharmacists was not allowed to present as the work had been funded by a tobacco company grant. Another colleague, who runs a vape shop and has helped many people to quit smoking, was also banned, and denied the chance to learn more about how to help smokers quit.
The conference was sponsored by Johnson and Johnson, makers of medical NRT that are losing market share to vaping products. This, apparently, is not a conflict of interest.
The National Conference on Tobacco and Vaping – Feb 2023
The Conference promotional materials promised:
“After two long years of balancing a pandemic response with continued work on tobacco and vaping in Canada, the 2023 National Conference “Charting the Course to less than 5% by 2035: Building on progress towards new gains” aims to help us re-focus on confronting the “big” issues that will help us get to 5% tobacco use prevalence.” “Over time, the conference has been one of a few venues where academia, advocates, policy makers, and frontline practitioners can come together to learn and strategize on the current and future issues facing the sector who address tobacco and vaping.”
(https://opha.on.ca/national-conference-on-tobacco-and-vaping-2023/ )
It seemed like this would be a great conference on a subject I am passionate about, so I registered to attend this virtual event. My credit card was processed, and I was sent login information on December 16th. On February 7th, the evening before the Conference, I received an email saying that they had cancelled my registration. The conference organizers seem to be using the Ottawa Model playbook.
The email stated: “As is customary with the norms of working in the tobacco control and vaping health sector, the conference does not allow those with ties to tobacco or vaping industry to attend. As we were reviewing your registration, we noticed that you were unable to declare that you are free from any connections to the tobacco or vaping industries. While we thank you for your interest in the conference, we are unable to allow you to attend the conference.” It is interesting that they have moved from not allowing people associated with the tobacco or vaping industry to speak at conferences to not allowing them even to attend. Also, they claim to be “unable” to allow me to attend when in fact they have simply chosen to ban me.
Ironically, a colleague who works full-time for a tobacco company was able to share his access to the presentations.
There was quite a bias against e-cigarettes in many of the presentations. I wonder if Health Canada, the CPHA or the OPHA have any concerns about a conflict of interest in having Johnson and Johnson as a platinum-level sponsor when e-cigarettes are directly competing with their business? In Canada, medical smoking cessation products are becoming less popular as people switch to vaping as a way to quit smoking, and J n J is losing income as a result. Johnson and Johnson ran a four-page NRT advert in the official program for the event. No vaping product advertisements were allowed.
Rob Schwartz acknowledged that smoking rates are decreasing more rapidly than expected, especially among youth. He showed graphs where teen vaping increased at the same time as smoking decreased. However, I was surprised that he did not even voice the possibility that teen vaping is acting as a substitute for teen smoking and contributing significantly to the decrease in tobacco use. He also participated in the “mission creep”, suggesting that anti-tobacco organizations should transition from being against tobacco to being against all forms of nicotine.
Dr. Peter Selby from CAMH talked about the role of vaping in smoking cessation. He mentioned EVALI and exploding vapes as reasons to avoid recommending vaping to people who smoke. Surely, he knows that EVALI was caused by illegal cannabis products sold in the USA, and that deaths from fires caused by smoking far outnumber the very rare cases of exploding vapes?
It was interesting to hear David Hammond say that many people seem to be using vape as an alternative to medical NRT. Use of NRT has decreased by about the same amount as the use of vape has increased. He also stated that vaping seems effective at getting people to quit in clinical trials, but this has not been reflected in population-level data. Maybe this is because no one is teaching people who smoke how to use vaping as a way to quit? No one would expect any other medication to work unless people are taught how to use the medicine properly.
Teen vaping rates in Canada
In general vaping rates remained unchanged between fall 2019 and winter 2021-22. Over 87% of Canadians aged 15-19 have not even vaped even once in the month before the most recent survey.
Teen smoking rates in Canada
In 2020, the prevalence of current cigarette smoking among youth aged 15 to 19 was 3%, a decrease from 5% in 2019. The prevalence of daily and occasional smoking among youth was unreportable due to the small sample size.
(https://www.canada.ca/en/health-canada/services/canadian-tobacco-nicotine-survey/2020-summary.html )
Between 2020 and 2021, the percentage of ” Current smoker, daily or occasional” in 12 – 17 year-olds had decreased from 1.8 to 1.1%. Again, the number of smokers was so low that these percentages might be inaccurate.
https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009610
“Some(academics) have concluded that the “gateway effect” has not been validated by evidence and that vaping products are reducing smoking at accelerated rates beyond predicted trends.” smoking rates among Canadians aged 15-19 are currently at an all-time low.”
National and provincial restrictions on vaping products in Canada (as of May 2022)
(Summarised from https://www.smoke-free.ca/SUAP/2020/Provincial%20regulations%20on%20vaping%20promotions.pdf with some updates)
Age
The minimum age for sale is 18 nationally, 19 in BC, MB, ON, NB, NS NL, YK, NWT, NU and 21 in PEI.
There is a ban on youth possession in AB and NU.
Tax
Vaping products tax exists in BC, SK, NS and NFLD. A national vape tax was instituted in Oct 2022 (https://www.canada.ca/en/services/taxes/excise-taxes-duties-and-levies/excise-duty-vaping-products.html ). In Quebec, an 80% tax has been discussed (https://thehub.ca/2023-01-31/quebec-slaps-new-taxes-on-vapes-even-as-research-suggests-doing-so-will-lead-to-higher-rates-of-smoking/ ).
In Nova Scotia vaping product tax revenue was $500,000 below the budget estimate of $2,332,000. The Government blames this on “consumption being lower than projected.” This may represent illicit trade or cross-border shopping. Tobacco tax revenue was higher than the estimate primarily due to an increase of 5.6 percent in the consumption of cigarettes. It is unclear if the increase in smoking was related to the vape tax or to a vape flavour ban that came into effect at the same time.
(https://notices.novascotia.ca/files/public-accounts/2021/pa-volume-1-financial-statements-2021.pdf )
Flavours
All flavours except tobacco are banned in NB, NS, and PEI. QU is working on a flavour ban as of April 2023.
In BC, SK and ON, only adult stores can sell flavoured vape. Vape only sold in specialty stores in PEI.
The proposed national flavour ban seems to have been abandoned.
The NS vape flavour ban may have contributed to a 5.6% increase in cigarette consumption, according to the Vaping Industry Trade Association (VITA). (https://www.newswire.ca/news-releases/nova-scotia-s-ban-of-vaping-product-flavours-increased-smoking-873638952.html )
Nicotine limit
The Nicotine Concentration in Vaping Products Regulations (NCVPR) establish a maximum nicotine concentration of 20 mg/mL for vaping products manufactured or imported for sale in Canada. The NCVPR also prohibits the packaging and sale of vaping products if the nicotine concentration displayed on the package exceeds 20 mg/mL.
Adverts
National ban on in-store ads and displays, except in adults-only locations.
National ban on broadcast ads, billboards, lifestyle ads, sponsorship and youth-appealing ads.
National health warning on packet.
Banned sales locations
Vaping is not allowed to be sold in hospitals in all provinces and territories except NB and YK.
They cannot be sold in pharmacies in any province or territory except BC.
Internet sales are banned in QU.
Ban on use in some locations
The majority of provinces and territories ban vaping in hospitals, schools, workplaces, public transit or private vehicles with minors inside. Some provinces ban vaping at outdoor events and facilities such as public beaches.
Other regulations
Plain packaging was implemented in BC but later rescinded.
Snus
Snus is legal in Canada and regulated as a tobacco product. It can be sold wherever cigarettes are sold, with similar restrictions.
In 2019 “Health Canada asked Swedish match (SM) what their plans are for introducing their products in Canada, to which SM indicated that it is not a market they are looking to expand to at this time as they are currently unable to meet the demand in the US.” https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/meeting-summaries-tobacco-vaping-industry/august-27-2019-swedish-match.html
Oral Nicotine Pouches
Health Canada calls these “Buccal nicotine.”They are not authorized in Canada.
“Health Canada is advising Canadians that nicotine buccal pouches (also known as tobacco-less nicotine pouches and oral nicotine pouches) have not been authorized in Canada. This means they have not been assessed by Health Canada for safety, efficacy and quality.”
“Unauthorized health products can present a number of serious health risks. For example, unauthorized nicotine buccal pouches may contain amounts of nicotine that exceed safe levels, or other ingredients not listed on the product label. Using products that contain unknown ingredients increases the risk of serious adverse or allergic reactions, or interactions with other medications and foods. Nicotine is a highly toxic and addictive substance.” This seems to vastly overestimate the risk of nicotine pouches, especially when used by people who smoke as an alternative to cigarettes.
The regulations about buccal pouches are un-necessarily complicated: Depending on the amount of nicotine the pouch delivers, a nicotine buccal pouch would be considered a prescription drug (if it delivers more than 4mg of nicotine/dose) and require a Drug Identification Number, or a natural health product (if it delivers 4mg or less of nicotine/dose) and require a Natural Product Numer. All nicotine buccal pouches need market authorization from Health Canada to be legally sold in Canada.
(https://oyston.com/blog/nicotinepouches/ )
Heated tobacco products
Available under the same regulations as cigarettes. Not widely advertised or readily available in Canada.
Conclusions
The Minister of Mental Health and Addiction and Associate Minister of Health, and Health Canada both make accurate statements about the relative risk of smoking and vaping. They recognize that vaping can be either an effective way to quit smoking or a long-term safer substitute for smoking.
They now need to spread this information so that every Canadian who smokes, everyone who loves someone who uses cigarettes, and every health care professional who cares for people who smoke, has ready access to this information and is encouraged to act based on the science.
The easy options would be to publish quotes from the Health Canada website on cigarette package inserts (or even in place of the health warnings on the outside of the packet) and allow vape store staff to quote from the Health Canada website and from Carolyn Bennett’s press release when talking to customers.
Cigarette manufacturers who claim to be interested in transitioning away from combustible tobacco and “Unsmoking Canada” should develop a medical-grade vape.
Health Canada should review its web pages on buccal nicotine pouches to make them consistent with its pages on vaping, and encourage manufacturers to market these products to Canadians who smoke.
Health Canada must urgently create a public information campaign to correct the widespread misinformation about the relative risks of smoking and vaping. Every month that they delay, 4,000 Canadians die who could have saved their own lives if they knew about alternative safer forms of nicotine.