Conflicts of interest statement

1. As a medical physician specialising in anesthesiology, I have seen people suffer and die un-necessarily from diseases associated with tobacco use.
2. As a result, I am passionate about decreasing the use of combustible tobacco, and in particular about persuading people who are addicted to nicotine as a result of cigarette smoking to switch to less harmful nicotine products either as a safer long-term alternative or as a way of quitting both tobacco and nicotine use.
3. I have worked for a variety of organizations that share my goal. This includes research, writing advocacy and educational programs that have been funded by vaping organizations and the tobacco industry, most notably Philip Morris International. Unfortunately, I have been unable to obtain funding for this advocacy work from organizations such as Health Canada, Physicians for a Smoke-Free Canada, the Canadian Cancer Society or the Heart and Stroke Foundation.
4. Details of my conflict of interest are posted publicly online as part of my blog at https://oyston.com/blog/sorry-not-sorry/

I have some comments to make about the current status of vaping and smoking in Canada. These are my personal professional opinions based on my own understanding of the issues. I have not been paid to write this submission.

SECTIONS

SMOKING AND TEEN VAPING RATES HAVE GONE DOWN

WHY DO SO MANY CANADIANS STILL SMOKE?

WHAT ARE HEALTH ORGANIZATIONS TELLING CANADIANS ABOUT VAPING?

CANADIAN HEALTH CARE WORKERS ARE IGNORANT ABOUT VAPING

“NO VAPING DEVICE IS APPROVED FOR SMOKING CESSATION”

“WE DO NOT KNOW THE LONG-TERM HEALTH EFFECTS OF VAPING”

SUMMARY

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SMOKING AND TEEN VAPING RATES HAVE GONE DOWN

Note that almost half of the young people who were vaping in 2019 had quit by 2023. The data from America also shows a 50% decrease in teen vaping. The so-called “epidemic” seems to be ending.

The largest decrease in smoking prevalence is in teenagers, who also have the highest prevalence of vaping. The smallest decrease is seen in the 55+ age group, who are least likely to vape. This is not a coincidence. The most likely explanation for the unexpectedly rapid decrease in teen smoking is that they are choosing vaping as a much safer substitute for tobacco smoking. This should be seen as good news and encouraged.

Not only is teen vaping (even defined very generously as vaping once in the last 30 days) decreasing, but the overall number of teens vaping is almost insignificant compared to the number of adults who are still smoking:

WHY DO SO MANY CANADIANS STILL SMOKE?

Now that teen vaping rates are decreasing, perhaps we can turn our attention to what is really killing Canadians: Cigarette smoking. Why are so many Canadians still smoking despite decades of Smokers Helpline, nicotine patches and gum, varenicline and bupropion? People who smoke know that it in a danger to their health, but they are unable to quit.  This is usually because they have become addicted to nicotine. However, there are several other much safer, but still enjoyable, sources of nicotine on the market: vaping, heat-not-burn products and oral nicotine pouches. All these products have all been shown to be many times safer than smoking. They have all been shown to be effective substitutes for cigarettes. But instead of promoting these alternatives, Health Canada and the health charities have been condemning them and working hard to make them less affordable (with high taxes) and less enjoyable (with flavour bans). Most people who smoke are not aware of the facts about the relative risks of smoking, vaping, and using nicotine pouches. If they were properly informed, many of them would choose to switch to safer nicotine product, just as consumers already look for healthier foods, less polluting cars or more efficient home appliances.

WHAT ARE HEALTH ORGANIZATIONS TELLING CANADIANS ABOUT VAPING?

There are signs that some health organizations are finally beginning to understand the role that vaping can play in reducing tobacco deaths.

Health Canada’s website (https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/quit-smoking.htm) states:

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 counseling to quit;

Do not currently report serious unwanted effects while using vaping products to quit;

The Canadian Cardiovascular Society Clinical Practice Update on Contemporary Approaches to Smoking Cessation (https://onlinecjc.ca/article/S0828-282X(25)00009-1/fulltext) states that:

“E-cigarettes are potentially valuable harm reduction tools for adults who smoke, especially those who are unable to use or quit with conventional evidence-based tobacco cessation treatments. Meta-analyses of randomized trials report strong evidence that e-cigarettes are effective to help people to quit smoking, with minimal harms when used short-term (6-12 months).Nicotine-containing e-cigarettes are effective for smoking cessation, and increase the odds of quitting by 2-3 times compared with placebo.”

The last statement should have been more strongly worded.. As long ago as 2019 the literature showed that vaping is not only better than a placebo, it is better than established nicotine replacement therapy. (A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy, Hajek, NEJM).

Furthermore, the authors of the guidelines fail to include vaping as an option in the treatment flowchart. Why?

Canada’s Lower-Risk Nicotine Use Guidelines from May 2025 (https://intrepidlab.ca/en/Documents/LRNUG%202025.pdf) states that:

“E-cigarettes may be used as a harm reduction tool for those who smoke. Tobacco users who have been unable or unwilling to quit smoking using current best evidence-based approaches, should switch completely to e-cigarettes to reduce exposure to cardiovascular toxicants and improve measures of cardiovascular function (where relapse to tobacco is not a concern). Long-term use should be avoided.”

The guidelines offer the following practical advice to people who smoke:

More frequent use (i.e. daily) of e-cigarettes is associated with an increase in cessation outcomes.

People who use combustible nicotine products should try to quit using approved smoking cessation treatments first. If they are unable or unwilling to quit, e-cigarettes can be considered.

E-cigarettes as a cessation aid may be most effective when combined with behavioural counselling.

Continued use of e-cigarettes may reduce risk of relapse to combustible tobacco.

People who smoke should be advised to switch completely from combustible tobacco to e-cigarettes and to use e-cigarettes when they would normally have smoked tobacco cigarettes.

There is no evidence for a specific device type or amount of nicotine that is most effective for cessation.

Switching completely to e-cigarettes will significantly reduce the harms associated with combustible tobacco.

This is all excellent information, and Canadians who smoke need to be made aware of this information.

Meanwhile, the Canadian Lung Association’s website (https://www.lung.ca/position-statement-vaping)  continues to publish outdated advice such as

“If you smoke and are using vaping to quit, know that there is not significant evidence to suggest vaping as an effective cessation support.”

Why is the Canadian Cancer Society not telling people who smoke that they can reduce their risk of cancer by switching from smoking to vaping? They call themselves “Your trusted source for accurate cancer information”, but they say that “Limited evidence in human and animal studies suggests that e-cigarettes can cause genetic changes and DNA damage, which may mean an increased risk for cancer.”, without pointing out that the cancer risk from e-cigarettes is much lower than from smoking tobacco.

The Cancer Society discourages smokers from using e-cigarettes as a way to quit by saying “For some people who smoke tobacco, using e-cigarettes may make quitting less likely” when the scientific evidence shows that e-cigarettes can help smokers quit.

Dr. Colin Mendelson summarises studies of the cancer risk from vaping in an article entitled “Switching from smoking to vaping dramatically reduces cancer risk “(https://colinmendelsohn.com.au/cancer/)

Stephens estimated that the lifetime risk of cancer from vaping is 0.4% of the risk from smoking

Murkett estimated that the lifetime risk of cancer from vaping is 0.23% of the risk from smoking

Rodrigo estimated that the lifetime cancer risk from vaping a closed vape system is 0.9-1.4% that of smoking

Scungio estimated that the lifetime lung cancer risk from vaping is 50,000 times less than from smoking

Avino estimated that the lifetime lung cancer risk from second-hand vapour is 50,000 times less than from second-hand smoke

Health Canada provides funding for many health charities. As a condition of this funding, they could reasonably require that the charities provide Canadians with accurate an up-to-date information that is consistent with Health Canada’s policy.

Health organizations are getting away with disseminating myths and misinformation about vaping partly because they are not permitting people with dissenting views to attend their meetings. Although I am a medical doctor, I have been banned from attending meetings arranged by the Canadian Public Health Association and the Ottawa Model for Smoking Cessation simply because, in the past, I have provided my medical expertise to groups such as the Canadian Vaping Association and Rights for Vapers. This is an infringement on my rights of free speech. Advising a vaping organization on how to defend itself in a court case should not result in a lifetime ban from attending public health conferences. Speakers at these conferences should be challenged by questions from an audience that includes people who consider that tobacco harm reduction with safer nicotine products is as valid as other forms of harm reduction.

CANADIAN HEALTH CARE WORKERS ARE IGNORANT ABOUT VAPING

In 2019 Health Canada conducted a survey of “Health Care Providers’ Views and Experiences with Smoking Cessation and Alternative Nicotine Products”.

The study found that 77% of Health Care Practitioners do not think that switching to vaping counts as stopping smoking. 53% think vaping with nicotine is “extremely” or “very” harmful, and 39% of family MDs think that nicotine vaping is as bad as smoking. Only 6% would recommend vaping as a way to quit smoking.

Nothing seems to have been done to imp-rove this situation and it is likely that most people who ask healthcare workers about quitting smoking would not be informed of the lates evidence on the safety and efficacy of vaping, as few physicians have read the guidelines from Health Canada, Canada’s Lower-Risk Nicotine Use Guidelines or the Canadian Cardiovascular Society Clinical Practice Update on Contemporary Approaches to Smoking Cessation.

A concerted effort is needed to ensure that Continuing Medical Education programs for healthcare workers contain accurate and up to date information about cigarette alternatives. This will not happen if attendance at the Ottawa Model for Smoking Cessation and Canadian Conference on Tobacco and Nicotine is limited to people who believe in prohibiting the use of nicotine. These conferences need to be open to people who can challenge the current orthodoxy, even if they have sometimes accepted funding from tobacco companies or vaping organizations.

People who smoke also need to be better informed. The quickest, most cost-effective, and most targeted approach would be to present this information in clear, plain language on cardboard slips, similar to old-fashioned cigarette cards, inserted into cigarette packages. Vape shop employees need to be able to tell potential customers that vaping is safer than smoking, and that it can help them quit, without fear of prosecution.

“NO VAPING DEVICE IS APPROVED FOR SMOKING CESSATION”

Every statement about the possible use of vaping as a method of smoking cessation always includes the statement that no vaping device has been approved for smoking cessation in Canada. Surely the 3.8 million Canadians who have so far been unable to quit smoking need a new alternative? The evidence clearly shows that vaping is more effective than conventional NRT at helping smokers to quit, so why are no vapes approved?

The easy answer is that no tobacco or vaping companies have submitted a product for Health Canada’s approval. Tobacco companies may claim that they want to “Unsmoke Canada” and transition to a world without combustible tobacco products, but they have steadfastly failed to seek approval for any of their vaping products.

The bigger question is why Health Canada has been so passive and ineffective. It is long past the time when Health Canada should have worked with vaping companies, pharmaceutical companies and universities to produce a vape designed to the highest safety standards and specifically manufactured and marketed as an aid to smoking cessation.

At the very least, every statement that “no device has been approved” should be followed by the clarification that this is only because no device has been submitted for approval.

“WE DO NOT KNOW THE LONG-TERM HEALTH EFFECTS OF VAPING”

However, we know that millions of people around the world have been vaping for decades with minimal ill-effects. We do know that Popcorn Lung is a myth, and that EVALI was caused by contaminated illegal cannabis products, even though these myths are widely used by anti-vaping propaganda organizations. We also know that in countries with excellent health surveillance systems such as the UK, there have been no deaths caused by vaping.

We know that in the short-term vaping may cause some coughing and exacerbate pre-existing asthma, and it has cardiovascular side effects similar to drinking coffee. It is probable that some people may be allergic to some components of vape juice. The psychiatric complications of vaping are more difficult to understand. It is not clear whether or not the adverse effects of nicotine on developing rodent brain apply to human teenagers. There is an association between depression and vaping, but this may be because people with depression are self-medicating with nicotine. Nicotine vaping may actually improve mood, concentration and possibly even help some students to study. Nicotine is already being studied as an aid for people with dementia.

Properly conducted studies of the health outcomes of vaping are sorely needed. Crucially they have to take into account prior smoking history. Many people who are currently vaping are unhealthy because they switched to vaping after experiencing poor health due to smoking.

SUMMARY

Alternative consumer nicotine products such as vape, heat-not-burn devices and nicotine pouches are much safer than smoking, and can be a pathway to quitting smoking. Many Canadians have already made the switch, which is probably why teen smoking rates in Canada and the USA are at historically low levels.

Health organizations should be encouraging this switch by providing people who smoke with accurate information and encouragement. Instead, perhaps because they believe that enjoying any form of nicotine is somehow immoral, they are using lies and misinformation to slow the transition from smoking to other much less harmful sources of nicotine. This is costing lives.

Health Canada needs to develop educational programs for both healthcare workers and consumers so that people who consume nicotine can make a rational and informed choice about the risks and benefits of switching from tobacco to vape or other consumer nicotine products.