Vype advert in a bus shelter: Is it really  “The perfect Puff?”

At the moment we are suffering the maximum possible harm from e-cigs with the least possible benefit.

Many teens are using an almost unregulated product which may be dangerous. They are getting addicted to nicotine, which encourages risk-taking behaviour and addiction to other chemicals.

Adult smokers who want to use vaping to quit are not being helped by the medical professions but left to get advice from unqualified staff in the local convenience store or vape emporium.

How can we maximize the benefits and minimize the risk of vaping with e-cigarettes?

JUL advert at point of sale in a Toronto convenience store

Cigarettes kill 45,000 Canadians per year. They are the #1 public health risk. Smoking prevalence is about 15% and it is no longer declining.  Smoking rates might be rising amongst youth as vaping may be a  gateway to smoking. The government is committed to reducing the percentage of people who smoke to 5% by 2035 but, apart from plain packaging, has no roadmap to get there. It is going to be hard to get another 10% of smokers to quit because the ones who could quit easily have already done so. We need a new tool in our kit bag.

When smokers deliberately use e-cigs containing nicotine with the intention of quitting smoking, many of them succeed. This is based on anecdotal evidence and proven in a British RCT which showed that 18% of vapers quit compared to 9.9% of people on conventional NRT. In the UK 20,000 people a year have used them to quit. JUUL claims it is helping millions to quit. The potential for good from e-cigs is enormous.

E-cigs are safer than tobacco. They contain few of the 7,000 noxious chemicals and 70 carcinogens present in tobacco smoke. Even though they do not burn tobacco, the vape does contain a variety of chemicals. Some are the same as in tobacco smoke but at much lower concentrations. They are not brand new chemicals, but products that workers have been exposed to at work or decades, so the toxicology is well known.  The exact risks are difficult to determine, as each vape liquid contains its own mix of ingredients  Public Health England said e-cigarettes are 95% safer, which may be an over-estimate.

The long-term risks of vaping are unknown and that no-one who does not currently smoke should start vaping. The potential harm is also enormous. Kids who have never smoked are getting addicted to nicotine, and some may go on to cigarettes. They are vaping unregulated substances with unapproved technology. Some vape chemicals are definite health hazards. Vape liquids which are said to be nicotine -free may contain nicotine.

How do we maximize the upside and minimize the downside?

These are my suggestions:

1) We ban the sale of all flavoured e-liquids except for the three or four smokers most often use to quit. This is likely unflavoured, tobacco flavoured and maybe menthol. Smokers who want to quit do not need a vast range of flavours to play with. Multiple flavours attract kids.

2) Ensure that the remaining flavours are as safe as possible and made to the highest possible standards. They must be made available in the nicotine concentrations smokers need to help them quit, including a guaranteed zero percent nicotine.

Flavours on display in a vape shop

3) We need to have at least one e-cigarette and one set of vape juices which are manufactured to the standards of medical equipment and pharmaceuticals. If JUUL is serious when it says that it is in business to help smokers quit, then they could be partners in this project. They could market a JUUL MD line of premium products approved for medical use.

4) A modified form of plain packaging should be used for vaping equipment and vape liquids. Vaping equipment needs only to come in one colour, perhaps matte black. Vape liquids labels should use a specified plain black font on a white background. Nicotine content should be clearly specified. There should be a warning that it should not be used by minors or by pregnant women unless under medical advice and supervision.

5 ) E-cigs and vape liquids should only be sold by pharmacies and licensed vape stores, which will lose their license if they sell to minors. In the pharmacy setting, they should be displayed next to the other nicotine replacement therapies. Pharmacists could then discuss vaping in the context of smoking cessation and offer a full range of treatments.

6) Both pharmacy and licensed vape stores could sell online. The combination of pharmacies, specialized vape stores and online sales should provide adequate opportunities for all smokers to access e-cigs.

5) Selling of vaping equipment in convenience stores needs to be banned. Convenience stores are notorious for selling to underage smokers and likely supply underage vapers.

6) Advertising should be banned or at least targeted at older people who smoke. It should be, for example, in golf and cruising magazines, not fashion and pop music magazines. It should not feature people under 30 years old vaping. Vaping should be associated with middle-aged smokers who shop for clothes at Walmart, not with actors, athletes and supermodels.

7) Once these issues have been resolved, we need a randomized controlled trial of the best available vaping technology versus the best practice in conventional NRT therapy. This would be large and costly, but an excellent use of government money. There has been a trial like this in the UK, but we need to replicate it in Canada with Canadian smokers and using products available in Canada.

8) In the long run, we have to think about ways to integrate vaping into our smoking cessation practice. For example, many smokers manage OK most of the time but have a hard time not smoking when socializing with friends who smoke. If they had an e-cigarette they could keep their friends’ company, dragging on something and making smoke, without the risks of tobacco. Nicotine patch with e-cigs for breakthrough would seem to be a possibility worth investigating.

9) E-cigs should then become available on prescription, and be covered by OHIP and/or drug plans.

10) Smokers should be encouraged to give up vaping once they have quit smoking and reduced their nicotine requirement to zero. No-one should be vaping for more than a year.

I do not think I am asking for anything too difficult here. The scale of what I am proposing is quite modest in relation to the size of both the tobacco and the vaping problems.

If we did what I am proposing Canada would be taking a middle path between the UK and the USA, as we so often do, and would once again be a world leader in smoking cessation.