Canadian regulations allowed huge international-owned vape manufacturers to market directly to Canadians in 2018. Huge advertising campaigns on social media by companies like BAT began in earnest. Products like VYPE will put our kids at risk. Many will become addicted to nicotine, made more glamorous and fun-loving by products that have flavours and slick packaging.
I made two main points in my piece: (1) It’s unclear this will benefit public health, because flavored e-cigarettes are attractive to current and would-be adult smokers who would benefit from switching, not just to teens trying nicotine for the first time; and (2) health impacts aside, this is an affront to personal freedom and responsibility. These arguments apply just as well to state-level bans as they do to a federal one.
Regarding the first point, though, I’d like to add some data I discoveredvia the American Enterprise Institute’s Sally Satel. Last year, theHarm Reduction Journalpublished the results of a surveyshowing definitively that fruit- and candy-flavored vaping products arenotjust for teenagers. Among adult smokers who switched to vaping in 2015 and 2016, only a quarter started their vaping use with tobacco flavoring.Currentuse of tobacco-flavored e-cigarettes was even lower. The most popular flavorings were “fruit/fruit beverage followed by dessert/pastry and candy/chocolate/sweets.”
Not every ex-smoker will return to his old ways if you make him use e-cigarettes that taste like tobacco instead of e-cigarettes that actually taste good. But it’s impossible to deny that these bans take away something that makes vaping more attractive than smoking, not just for teens but also for adults. Since vaping is about 95 percent safer than smoking, that’s to be celebrated, not banned.
In a sign of the seriousness of the e-cigarette investigation, officials disclosed that the enforcement arm of the U.S. Food and Drug Administration has been conducting a probe in parallel with the public health investigation led by the Centers for Disease Control and Prevention. Officials said they still do not know the cause of the lung injuries that are making people so sick. There have beenseven confirmed deaths.
All reported cases had a history of e-cigarette or vaping use, officials have said. Initial data shows that most people had a history of using e-cigarette products containing THC, that many people said they used both nicotine and THC, and that some reported using only nicotine products. Many people have also said they used black market or illicit THC products. THC is the active ingredient in marijuana that produces the high.
FDA officials said investigators from its Office of Criminal Investigations have been pursuing a parallel investigation since shortly after the illnesses were first reported this summer. That office conducts criminal investigations of illegal activities involving FDA-regulated products, arresting those responsible and bringing them before the Justice Department for prosecution.
To allay fears of sick patients who have used illicit marijuana products, some of whom have been reluctant to share information with public health officials, the FDA is not pursuing prosecution of people for personal use of any controlled substances.
“The focus is on the supply chain,” said Mitch Zeller, director of FDA’s Center for Tobacco Products. “We’re all alarmed by reports about THC-containing products,” he said, even if THC has not been present in every case.
In some states where marijuana is not legal, the only way for someone to purchase a THC product is “buying it in an alley or on the street,” Zeller said. “I would be very, very careful about doing that,” he warned, because consumers have no way of knowing “what might have happened along the way from the product being put in the hands of the end user to the moment of aerosolization or inhalation.”
Health officials are warning people who are concerned about these specific health risks to consider refraining from using e-cigarette or vaping products. If adults are trying to quit smoking by using nicotine-containing e-cigarettes, they should not return to smoking cigarettes.
Marijuana industry experts have said that black-market operators have added thickening agents to THC oil that is used to fill vape cartridges. At least one such “cutting agent” used to dilute solutions,vitamin E acetate, an oil derived from vitamin E, has been found in samples tested bystate labsand the FDA’s forensics lab. But officials cautioned again Thursday that they have not identified a single e-cigarette product or substance as the underlying culprit. A form of chemical exposure is suspected of making patients ill.
The FDA is analyzing more than 150 samples collected from patients across the country who have fallen ill and is testing them for a broad range of chemicals, including nicotine, THC, cutting agents and other substances.
Vitamin E acetate is commonly available as a nutritional supplement and is used in topical skin treatments. It is not known to cause harm when ingested as a vitamin supplement or applied to the skin. Its name sounds harmless, experts said, but its molecular structure could make it hazardous when inhaled. It could be associated with the kinds ofrespiratory symptomsthat many patients have reported: cough, shortness of breath and chest pain, officials said. In some instances, they have also reported vomiting or diarrhea.
“This is a complex investigation that spans many states and involves hundreds of cases and a wide variety of substances and products,” Anne Schuchat, the CDC’s principal deputy director, said during a call with reporters. “We at CDC are very concerned about the occurrence of life-threatening illnesses in otherwise healthy young people reported from around the country.”
Schuchat said a variety of hypotheses are being considered. “There may be a problem with source material or modification that may be occurring at different places,” she said, adding that “it may take some time” to obtain definitive answers.
More than half of the reported cases are in people under 25, Schuchat said. Boys and men make up three-fourths of the patients; two-thirds of patients are between 18 and 34, and 16 percent are younger than 18.
Some of the additional cases reported Thursday are from investigations conducted several weeks ago, Schuchat said. But new cases continue to be reported in the ongoing outbreak, she said.
Illinois’s chief medical officer, Jennifer Layden, said state officials hope to find more clues by collecting information from people who vape but have not gotten sick. Some of Illinois’s 69 patients are unable to talk to health-care professionals because of the severity of their illnesses or because they are reluctant to share information about illicit products they have used, she said.
Officials plan to use social media to solicit responses for an anonymous survey about vaping habits to help identify what is making people sick, she said.
On Monday, California reported the death of a 40-year-old man from vaping-related illnesses. That death is at least the fifth reported in amiddle-aged or older person.
Call from health coalition comes after officials announce 1st Canadian case believed to be linked to vaping
CBC News·
Various health groups in Canada want Ottawa to step in to address a vaping situation they are calling a crisis.(Craig Chivers/CBC)
There's an urgent need for vaping products to be given the same advertising and flavour restrictions as tobacco, a group of health organizations in Canada said in calling for immediate political action.
The appeal came Thursday at a news conference in Ottawa from representatives of:
Action on Smoking and Health.
Canadian Cancer Society.
Canadian Medical Association.
Canadian Lung Association.
Coalition québécoise pour le contrôle du tabac.
Heart & Stroke.
Ontario Campaign for Action on Tobacco.
Physicians for a Smoke-Free Canada.
"We've just unleashed a torrent of addiction amongst young people in Canada through our thoughtless disregard of the need for effective regulation of these products," Dr. Andrew Pipe, Heart & Stroke board chair and a smoking cessation physician in Ottawa, said in an interview. "Now we're playing catch-up in Canada, and we're in an almost unforgivable situation."
On Wednesday,health officials in London, Ont., announced what's believed to be the first case in Canada of a respiratory illness linked to vaping. The high-school-age individual used e-cigarettes daily, was initially on life-support and is now recovering at home.
The key missing piece of information in London's case is what was in the cartridge, said Dr. Samir Gupta, a respirologist and associate professor in the department of medicine at the University of Toronto.
Public hospitals in Ontario have been asked to provide the province's chief medical officer of health with statistical, non-identifying information related to incidences of vaping-related severe pulmonary disease.
"Clinicians have reported to Toronto Public Health [TPH] that they had encountered a small number of patients in recent weeks who potentially had vaping-related severe illness," Dr. Michael Finkelstein, Toronto's associate medical officer of health, said in an emailed statement.
TPH said it has asked clinicians to ask their patients to share illness-related information. "We have yet to receive this information," Finkelstein said.
The U.S. Centers for Disease Control and Prevention (CDC) reported 530 confirmed and probable cases of lung injury related to e-cigarettes as of Tuesday. The agency said Thursday that based on gender and age information on 373 people, 72 per cent were male and 67 per cent were 18 to 34.
No single device, ingredient, additive or pathway to illness has been identified in the U.S. investigation. Most of the people reported using tetrahydrocannabinol (THC, the main component in cannabis that gives users a high) or both THC and nicotine. Some of the cases have reported using only nicotine, CDC said.
The U.S. Food and Drug Administration is now investigating more than 150 products and substances and said it has activated its criminal investigations arm to explore the supply chain of vaping products and identify the cause of the illnesses. No individual vapers will be targeted, said Mitch Zeller, director of the FDA's Center for Tobacco Products.
During the current Canadian election campaign, the health groups involved in Thursday's news conference called on all parties to commit, within 60 days should they form government, to stop promotions for vaping products on television, radio, billboards, public transit hubs, convenience stores, social media, newspapers and other mainstream media.
Dr. Sandy Buchman, centre, president of the Canadian Medical Association, and representatives of other health organizations called on the federal government to treat vaping like smoking.(Fred Chartrand/Canadian Press)
The groups said manufacturers are allowedto entice youthand non-smokers with attractive flavours, give the products away and have no obligations for nicotine limits or health warnings on packages as in this case for tobacco.
The medical groups want a nicotine level restriction of 20 mg/mL similar to in the European Union. The current maximum is 66 mg/mL. The U.S. has no nicotine limit for e-cigarette products, said Rob Cunningham, senior policy analyst with the Canadian Cancer Society.
"We do not need to wait for a death in Canada to warrant action," said Terry Dean, CEO of the Canadian Lung Association.
In Ontario, advertising of e-cigarettes is currently permitted in convenience stores and gas stations.
"Once we understand what the concern is, then we'lllook at any steps necessaryin order to protect the health of our young people," Ontario Health Minister Christine Elliott said Thursday.
Keep on top of symptoms, Health Canada urges
The Canadian Vaping Association said it wants federal, provincial and territorial governments to immediately ban certain marketing. The group said it represents vape store owners, not vaping brands.
Advertising "must be removed from all convenience stores, gas stations or any retail location that is not age restricted," the association said in a statement.
Health Canada has been urging people who vape to watch for symptoms such as coughing, shortness of breath, fatigue, diarrhea, vomiting and chest pain. It has also said health-care professionals should ask patients about their use of e-cigarette products if they have respiratory symptoms.
Health Canada said Thursday it has consulted on proposed new regulatory measures to further restrict vaping product advertising "to protect youth from inducements to using these products, including restricting the display of vaping products at points of sale."
The U.S. media companies CBS, WarnerMedia and Viacom said they'll drop e-cigarette advertising, CNBC reported.
In the U.S., Michigan and New York state have voted to ban flavoured e-cigarettes.
Vaping is quickly becoming a lot more popular with Canadians, despite what little is known of its long-term health effects.
Experts say part of the reason for the surge in use in such a short time is the evolution of the devices themselves.
"We used to say that cigarettes are the most effective way of consuming nicotine, but e-cigarettes have replaced them," said Dr. Robert Schwartz, a senior scientist at Toronto's Centre for Addiction and Mental Health (CAMH).
"They're so small and discreet and these new devices don't create the huge clouds that the previous devices did — people can use them anywhere, all the time."
Newer devices such as Juul or Vype, which came to the Canadian market last fall, mimic the physical feeling of a cigarette on the throat and use what are known as "nicotine salts" to deliver higher concentrations of the drug to the brain — much in the same way that cigarettes do.
"It used to be that if the nicotine concentration was too high, it would give you a harsh or aversive feeling on your throat," says David Hammond, a public health professor at the University of Waterloo who researches vaping in youth.
"Juul solved that. That's why Juul is somewhere around half the market. That's why most of the other major brands in Canada, including Vype and the smaller ones, have switched to nicotine salts."
E-cigarettes themselves aren't new, having been first introduced in Canada in 2004, according to the Heart and Stroke Foundation, but the chemistry behind the devices has changed dramatically in the past two years with new players on the market.
Schwartz says before the use of nicotine salts in products like Juul, the highest nicotine concentrations commercially sold in Canada were typically upward of 20 milligrams per millilitre, which is the regulated limit in the European Union.
The maximum amount of nicotine content allowed in e-cigarettes in Canada is currently 66 milligrams per millilitre, according to Health Canada. The Canadian Cancer Society says the highest amount used in Juul products is 59, and 57 in Vype.
Juul says one of its cartridges, or pods, has roughly the same amount of nicotine as a pack of 20 cigarettes.
"Once they solved the chemistry of palatable nicotine delivery, then all those others factors that were responsible for vaping becoming popular," Hammond says.
"You throw in tasty flavours and boom you have a wonderful little drug delivery device that sits in your pocket."
Smoking alternative
Eva Egnatieva, 16, started using an e-cigarette two months ago and admits she doesn't know exactly why.
"My friends, they're older than me and they're all smoking this," the Toronto high school student said while inhaling a Juul e-cigarette between classes.
"I think when I'm nervous or I have some problem, I smoke it and I'm relaxed, not worried."
Egnatieva says that while she's never smoked a cigarette, she started using an e-cigarette without nicotine at the age of 15. She says the first time she tried an e-cigarette with nicotine in it she hated it, but stuck with it.
"I only smoke Juul," she says. "I don't like to smoke cigarettes because I hate the smell of cigarettes."
Egnatieva says she has little knowledge of the long-term health effects of using the device, but it doesn't discourage her from using it and has no plans to quit.
Leo Ting, a 38-year-old University of Toronto faculty member, says he transitioned to using an e-cigarette to quit smoking three years ago.
"I've gotten to the point to where I touch a cigarette and I do not want to have another one," he says.
"Which is not something that was the case when I was trying to cold turkey it before, so this has helped in that case."
He says he hopes to stop vaping completely in about a year, in order to lower the chances of having a relapse, and has been gradually lowering the amount of nicotine he consumes in the device.
Surge in popularity
Hammond says the growing popularity of e-cigarettes in Canada is in part because of their use as a tool to quit smoking, but also because of their attractiveness to young people.
"Juul has both made them more likely to help smokers quit, it's also made them more likely to bring new non-smoking youth into the market," he says.
"We need to make them available to adult smokers; we still have five million Canadians that smoke, but we've done a poor job at framing these products as something you use to quit smoking, rather than something you take to a party on Friday night when you're 17."
Juul opened its first retail store in Toronto this summer.(Albert Leung/CBC)
Hammond led a study published in the British Medical Journal last June, based on online surveys of Canadians aged 16 to 19 in 2017 and 2018, which found that the number of Canadian teens who said they had vaped in the last month had grown 74 per cent, from 8.4 per cent in 2017 to 14.6 per cent in 2018.
New data from the U.S. National Institute on Drug Abuse show a significant increase in teenagers in grades eight, 10 and 12 who say they have used an e-cigarette since 2018. One in 11 U.S. students in Grade 8 reported they had vaped in the past month in 2019, one in five in Grade 10 and one in four in Grade 12.
"What we're seeing now is rapidly increasing rates of e-cigarette use in teens and young adults," says Dr. Nicholas Chadi, a pediatrician at CHU Sainte-Justine in Montreal and addiction medicine specialist.
"They've been very aggressively marketed in all sorts of forms — social media and big billboard ads — to target young people, even though companies will say the contrary. The marketing strategy has worked very well."
Health concerns
On Wednesday, health officials in London, Ont., announced what's believed to be the first case in Canada of a respiratory illness linked to vaping. The high-school-age individual used e-cigarettes daily, was initially on life-support, and is now recovering at home.
While it's not yet known what was in the cartridge, Health Canada says it's concerned by reports of severe pulmonary illness as well as the increase in vaping reported among Canadian youth and it's considering "additional measures" regarding the role of flavours, nicotine concentration and product design, and how all of that contributes to vaping's appeal to youth and non-smokers.
Canadian doctors call for a crackdown on vaping
02:03
Call from health coalition comes after officials announce first Canadian case believed to be linked to vaping.2:03
Toronto Public Health reported Thursday they had also encountered a small number of patients in recent weeks who potentially had a vaping-related illness.
The U.S. Centers for Disease Control and Prevention reported 530 confirmed and probable cases of lung injury related to e-cigarettes as of Sept. 17, including at least seven deaths.
"This remains a relatively new phenomenon in our country so we're still wrestling to understand the long-term health effects, but certainly the short-term are incredibly concerning," says Terry Dean, president and CEO of the Canadian Lung Association. "We certainly cannot view them as harmless, because they're not."
Dean says appropriate regulation, policy and education led to the curbing of tobacco consumption rates in Canada and he believes a similar approach should be taken as soon as possible with e-cigarettes and in particular where they're accessible for youth.
"If you're not vaping today — don't start. Blanket statement," he said. "If you are vaping to help stop smoking, your end goal should be to stop vaping."
Chadi says there has never been such a "rapid uptake" in the history of recorded substance use in teens, many of whom may not know how addictive they are and how much nicotine they contain.
"There is some research that shows for young people ages 25 and under with a brain that's still changing, these devices are not an effective smoking cessation tool because you can get very hooked up to the nicotine that comes with it," he says.
"Doctors, pediatricians, but also dentists, social workers and school nurses need to ask the right questions to teens to know if they're using them, what they think about them and try to help."
According to the U.S. Centers for Disease Control and Prevention (CDC), there are currentlysix deaths and 380 confirmed or probable casesof severe lung disease due to vaping. As oneeditorial writerin a medical journal put it, “there is clearly an epidemic that begs for an urgent response.”
E-cigarettes have exploded in popularity in recent years, especially among teens. Between 2011 and 2018, the percentage of U.S. high school students using them skyrocketedfrom 1.5 percent to 20.8 percent.
This surge in popularity is probably explained by a combination of factors.
Amarketingstrategy geared toward teens and making effective use of social media has clearly played a role. Just recently, the U.S. Food and Drug Administration sent awarning letterto JUUL about their advertising, citing a school visit where a representative allegedly claimed that their product was “totally safe” and stated that a student “should mention JUUL to his (nicotine-addicted) friend …because that’s a safer alternative than smoking cigarettes, and it would be better for the kid to use.”
Another reason that e-cigarettes have become so popular is that they come in a variety of flavours, unlike regular tobacco products. Flavoured cigaretteswere made illegalin Canada in 2009. According to oneanalysis, nearly one-third of users started vaping because of e-cigarette flavours, and these flavours, particularly fruit flavours, were more likely to influence younger adults 18-24 years old than older ones. Given their role in encouraging vaping, and the suggestion that the flavourings themselves might bedangerous, Michigan recentlybannedflavoured e-cigarettes. Other jurisdictions may soon follow.
While many people use e-cigarettes as a means to quit smoking, the evidence for their effectiveness is somewhat underwhelming. A 2013 Lancetstudyfound that e-cigarettes performed about as well (or as poorly) as the nicotine patch, with quit rates of 7.3 percent vs. 5.8 percent at six months. A more recent New England Journal of Medicinestudyfound that e-cigarettes outperformed other nicotine replacement products with quit rates of 18 percent vs. 9.9 percent. However, an important caveat to the NEJM study is that 80 percent of patients who “quit” smoking were still using e-cigarettes at one year, whereas most people (over 90 percent) who quit with something like the nicotine patch ultimately stop using it. Thus, e-cigarette users did not so much quit smoking as switch from cigarettes to e-cigarettes.
The tendency to use e-cigarettes indefinitely is why this recent cluster of vaping-related lung disease is such a concern. Why this sudden uptick of cases has come about is not entirely clear.Case reportsof severe respiratory failure from vaping are not new. Some date as far back as2015. Thus, it’s possible that cases were going undiagnosed or unappreciated until the current episode made everyone take notice.
Anotherpotential culpritis tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis. Many, though not all, of the e-cigarette samples tested by the FDA contained THC. Another interesting finding is that many, but again, not all, of the samples, contained high levels of Vitamin E acetate, which has led to suspicions that it might be responsible.
While it might seem implausible that a vitamin or its derivative could cause hundreds of cases of lung disease, it is worth remembering two important points. Taking something orally is not the same as inhaling it into your lungs. Second, vitamin E is not a benign substance, and ameta-analysisof 19 trials found that high doses of vitamin E increased mortality.
For now, no single cause can be blamed for these cases and the best advice is probably that issued by theCDC. Consider not using e-cigarette products and, irrespective of the investigation, remember that the use of e-cigarettes isunsafe for children, teens, and young adults.
As more stories come out about the risks of vaping, eight Canadian health organizations have calledfor urgent actionfrom the federal government to treat vaping like smoking.
But what exactly are the health risks of vaping? Here’s what you need to know.
What is causing vaping-related injuries?
While much is still unknown, the CDCsaid in a press releaseon Thursday that they are tracking vaping-related lung injuries. The organization said that based on data, most patients who have experienced the illness have reported using e-cigarette products containing THC — a cannabinoid found in cannabis.
Additionally, data shows that many affected patients reported vaping THCandnicotine, although some patients reported using e-cigarette products containing only nicotine.
Symptoms of vaping-related lung injury include cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever or abdominal pain,the CDC reported.
WATCH BELOW: Coalition of health care organizations calls for action on young people vaping
According toDr. David Hammond, a professor of public health at the University of Waterloo in Ontario, most of the severe vaping-related illnesses are likely due to contamination. Hammond’s research focuses largely on nicotine, drug and public health policy.
“The CDC, through some of the testing, has identified that in some of the THC products people used is what would be considered a contaminant,” Hammond told Global News.
“The working hypothesis is that at least some — possibly most — of these cases are not involving nicotine, and are likely due to some sort of contaminant; something in there that shouldn’t normally be in there.”
In other words, Hammond says this likely means poor manufacturing and bad batches of products may be a factor in the outbreak.
As of now, there is no consistent e-cigarette or vaping product identified in all vaping-related illness cases, Hammond explained. There is also not one single product or substance “conclusively linked to lung disease in patients,” the CDC noted.
On Friday,Reuters reportedthat the U.S. investigation into the life-threatening lung illness has found that many patients had “pockets of oil clogging up cells responsible for removing impurities in the lungs.”
Researchers are trying to determine where the oil came from.
WATCH BELOW: Ontario teen diagnosed with vaping-related illness
One theory, according to Reuters, is that the oil deposits are residue from inhaling vaping oils, such as those containing THC or vitamin E acetate. Both are considered possible contributors to the current illnesses.
“Vitamin E is in lots of foods, but if you heat it and inhale it, it can be toxic,” Hammond explained.
The harms of nicotine
Even outside of severe lung illness or injury, health experts are concerned with vaping — period. Most e-cigarettes contain nicotine, theCDCreports, and nicotine is addictive and harmful to people at any age, but especially youth.
The stimulant can harm the developing adolescent brain, affecting the parts that control attention, learning, mood and impulse control the CDC noted.Research has found that there’s a “strong and robust” linkage between vaping and subsequent tobacco use.
Health Canada also saysthat nicotine can affect memory and concentration. Vaping liquid containing nicotine can be very harmful, the government agency notes, if it’s swallowed or absorbed through the skin.
Hammond adds that there’s also concern around pregnant women vaping, and their unborn children being exposed to potentially harmful chemicals.
Long-term risks of vaping still largely unknown
Hammond said that while vaping should not be considered safe, the long-term health effects are still not fully known. Vaping may be safer than smoking cigarettes he adds, but it still poses potential harm.
WATCH BELOW: Why teens get into vaping
“Most of the chronic diseases that people hypothesize might be involved [in vaping] are things like cardiovascular disease and other lung problems,” Hammond said.
“Those do take a decade or two before they appear, just as the case for smoking… it’s not a benign activity.”
— With a file from the Canadian Press and files from Reuters
