Several consumer products can act as safer alternatives to deadly cigarettes, but they are not being promoted effectively. In fact, more and more political action is making them less pleasant, more expensive, and more difficult to obtain. Health Canada needs to radically rethink its attitudes to safer nicotine products such as vape, heat-not-burn, snus and nicotine pouches. Millions of lives are at stake.

This is the full text of a letter to Mark Holland, the Health Minister and Ya’ara Saks, Minister of Mental Health and Addictions.

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Dear Minister Saks and Minister Holland:

As a physician who has been involved in tobacco control issues for over 15 years, I am writing to urge you to adopt a more effective approach to tackling the #1 cause of preventable deaths in this country.

1. The Issue

Today over one hundred Canadians will go to a convenience store, supermarket or gas station to buy the pack of cigarettes that will tip them over the edge from being someone with a bit of a smoker’s cough to someone who is destined to die from tobacco-related diseases. Those cigarettes will make one of their lung cells turn cancerous, begin the creation of a plaque that will eventually cause a fatal heart attack or stroke, or cause some other fatal condition. It is just a matter of time.

Every day, the 3.5 million Canadians who still smoke play a game of Russian roulette. Forty-six thousand (46,000) of them die from tobacco-related diseases every year.  They know that there is a greater than 50% chance that smoking will kill them. They know that they should stop. Most of them want to stop and have tried many times. They have been to stop smoking clinics, talked to a nurse or pharmacist, bought the gum and the patch, and been prescribed medications like varenicline and bupropion, but they are still smoking. Traditional medical treatments for “Tobacco Use Disorder” are very ineffective, failing about 80% of the time. 
 Canadians who smoke have a toxic relationship with nicotine. When they try to break free from smoking, the siren song of nicotine overpowers them with cravings and withdrawal symptoms. Embarrassed, ashamed, humiliated and defeated, they resume smoking.

2. Safer alternatives to cigarettes have reduced tobacco-related deaths in other countries

Swedes consume as much nicotine as anyone else in the European Union, but they take it as snus, small packages of purified tobacco they put in their mouths. As a result, Swedish men have the lowest incidence of lung cancer– less than half the EU average – and the lowest rates of oral cancer in Europe. In fact, Swedes have the lowest rate of tobacco-related deaths of any country in Europe.

The Japanese use heat not burn devices, which create a tobacco-flavoured vapour that is much less toxic than tobacco smoke because it is not burnt. In the eight years since they were introduced in Japan, cigarette consumption has declined by 55%.

The British and New Zealand governments are promoting vaping as a way to quit. Vapes are tobacco-free products that contain. Public health authorities in the UK say they are 20 times safer than smoking. They have been proven to be so much more effective at getting smokers to quit than nicotine patches or gum that the British government is giving free vapes to smokers in a “Swap to Stop” campaign.

3. Canada urgently needs a scientific and evidence-based approach to promote smoking cessation and nicotine harm reduction.

Canada’s Tobacco Strategy (CTS) is designed to help achieve the target of less than 5% tobacco use by 2035 by helping Canadians who smoke to quit or reduce the harms of their addiction to nicotine. The CTS also notes that giving people who smoke access to less harmful options than cigarettes will help reduce their health risks.

Health Canada should be encouraging adults who smoke to switch to safer nicotine products. Their own surveys show that almost no one, not even physicians, is aware that these alternative nicotine products are many times safer than smoking and can help wean Canadians who smoke off using deadly combustible tobacco products. 

Stopping smoking does not have to be a medical procedure requiring professional supervision. It can be as simple as going to a store and buying a vape or nicotine pouches instead of cigarettes. This is fortunate, as these alternatives are not currently being offered to smokers by stop smoking clinics or health care workers.

There should be a massive educational campaign aimed at both the public and health care professionals, presenting the scientific data that proves that cigarette alternatives such as vape, heat not burn, and nicotine pouches greatly reduce the health risks associated with consuming nicotine and are much safer substitutes for cigarettes.

Nicotine pouches, another effective alternative to cigarettes, have recently been legalized in Canada.  They are a tobacco-free version of snus. As they contain no tobacco, are not burnt, and nothing is inhaled, they are at least as safe as nicotine gum or lozenges and about 100 times safer than smoking. People who smoke prefer them to using gum, and they are more likely to quit using pouches than gum. Health charities were outraged that the legislation allowed pouches to be legally sold to minors. Instead of legislating a minimum legal age, the Health Minister banned flavoured pouches and restricted sales to pharmacies only.


4.  Establishing evidence-based policies to prevent teenage vaping.

Youth uptake of nicotine products is an important issue. Politicians and Health Canada should be concerned, but a careful assessment of the science and statistics should temper this anxiety. Vaping does not act as a gateway to smoking. In fact, teen smoking levels are the lowest ever recorded in Canada. The only reasonable explanation for this is that vaping is diverting some teens away from smoking. Instead, they are choosing a much less dangerous nicotine product.

Teenage vaping should be viewed in the context of other issues that are a risk to youth. Flavoured alcohol drinks, cannabis products, and opioid misuse are far greater dangers than vaping.

Banning flavours as a way of deterring teens from vaping is a misguided policy that is not based on evidence.  Flavours are an intrinsic part of vaping. Almost no one drinks unflavoured alcohol, and almost no one uses unflavoured vapes.). Adults and adults both prefer fruit and dessert-flavoured vaping products to unflavoured or tobacco-flavoured products. To ban adults from using flavoured vape and require them to use a tobacco-flavoured product to quit smoking makes as much sense as trying to cure an alcoholic with whisky-flavoured medicine. It defies logic to allow fruit-flavoured nicotine gum to be sold openly in pharmacies while insisting that nicotine pouches can only be marketed in tobacco and menthol flavours and must be hidden behind the counter.

There should be a minimum legal age for purchasing all nicotine products. Existing age limits on the sale of vapes need to be much more strongly enforced. Anyone who provides nicotine products to minors should be prosecuted, whether they are doing so as a business or as a “favour” to a friend or relative.


5.  Health policy should follow the science, not the hysteria.

Health Canada and the Health Minister are being goaded by misguided medical charities such as “Physicians for a Smokefree Canada,” the Canadian Cancer Society and the Heart and Stroke Foundation to make cigarette alternatives as unpleasant, expensive, and difficult to obtain as possible.  These organizations promote taxation, flavour bans, and restrictions on where these products can be sold.

This misguided policy will likely create a dangerous, completely unregulated black market. It will deprive people who smoke from having the opportunity to save their own lives.  If Health Canada gives in to this pressure, it is complicit in condemning Canadians who smoke to a lingering and unpleasant death.

 
6.  Conclusions and recommendations.
 

Education: 

People who smoke should be honestly informed of the relative risk of alternative nicotine products. People who treat “Tobacco Use Disorder” should include safer nicotine products in their therapeutic armamentarium.

Availability: 

Safer nicotine products should be sold wherever tobacco is sold. If we trust supermarkets, gas stations and convenience stores to restrict cigarette and alcohol sales to adults only, then we should trust them only to sell vapes to adults.  If we cannot trust them with the least deadly of these products, then we should not trust them to sell any form of nicotine or alcohol.

Ensure that safer alternatives are as enjoyable as possible:
End flavour bans on nicotine pouches and do not institute a flavour ban on vapes. Continue to ban flavoured cigarettes and cigars.

Make taxation proportionate to risk:
Less dangerous products should have lower taxes than the most dangerous products to create a financial “nudge” to quitting. Those who smoke cigarettes are more costly to our health care system than those who use safer alternatives.

Legislation:
Establish and enforce a minimum legal age for nicotine pouches. Rescind provincial vape flavour bans and federal nicotine pouch flavour ban. Allow all cigarette alternatives, including nicotine pouches, to be sold alongside cigarettes in convenience stores, gas stations and supermarkets.

I have sent copies of this letter to Hillary Morgan, Director of Operations: Office of the Minister of Mental Health and Addictions and Associate Minister of Health and Sonia Johnson. Director General Tobacco Control Directorate at Health Canada.

This letter represents my opinions as a physician who has been involved in tobacco control issues for decades. I have received no payment for it from the tobacco or vaping industries.

 

Yours Sincerely

 

Dr. John Oyston, MB BS, BMedSci, FRCA, FRCP(C) 

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To learn more, please check out my blog posts:

A New Approach to Smoking Cessation

Zonnic could save a million lives. Health organizations want it banned. Why?

Teen vaping has eliminated teen smoking: An accidental success story