Reversing Fortunes in Tobacco Harm Reduction

There are credible rumblings that the federal government will be revisiting the regulation of nicotine vaping in Canada. If sources are correct, we can expect a release in the Gazette in October following the resumption of parliament with a second release closer to year end. First up will be nicotine, specifically nicotine limits, followed by the flavours used in e-liquid. The timing is odd but then everything about this story is. If you don’t follow the vaping file closely, the last news release (announcing a ban on advertising vaping products) was only issued on July 8th, 2020, a short time ago. This while the industry and manufacturers are in a  race to meet the January 1st deadline for new product requirements to replace those currently on the market, following the prior release. We’re in the middle of a pandemic and an overdose crisis related to a poisonous drug supply and a very passionate and public conversation about people on the margins. It takes a special kind of tone-deaf to have limiting the options of smokers and former smokers on your radar, and yet here we are. 

The nicotine conversation will be a contentious one. Currently, the limit for nicotine in e-liquids is set at less than 66 mg/ml. Most products on the market in Canada are sold at 50 mg/ml or less. Word is, the government would like to drastically reduce the nicotine limit to 20 mg/ml, as it is in some other jurisdictions like the European Union. No doubt that will be the reasoning they put forward for choosing 20 mg/ml, as there is no scientific basis for choosing that as a limit. In fact, Dr. Konstantinos Farsalinos, whose work was referenced in determining the 20 mg/ml limit for the EU., argued that his work had been misinterpreted and was against the limit. He argued instead that 50 mg/ml would more closely simulate the effect of a cigarette and therefore would be more effective, especially for resistant quitters. If the goal is to have people quit smoking, 50 mg/ml reaches more people in the target group. The full letter, Scientific Errors in the Tobacco Products Directive, addresses several key errors in the directive.

With the government’s rather lofty goal of decreasing smoking from about 15% down to 5% by 2035, one might expect that the government would want every tool in its toolbox. But there have been signs that the government’s eye is wandering. Instead of a strict focus on reducing smoking and smoking-related deaths, the language has changed to a focus on reducing ‘nicotine use.’ This is echoed in the statement from the Chief Medical Officers, earlier this year, in which they begin, “We recommend that Canadians needing support with nicotine addiction speak to a health care provider and seek out proven cessation therapies, such as medication or approved nicotine replacement therapies.” While I do understand what they mean by “proven” it is worth bearing in mind that these “proven” methods do not work for most people, at less than 10% effectiveness

The interesting part, for me anyway, is that they refer to “Canadians needing support with nicotine addiction…” rather than to “smokers” as has been the convention in past. While one might read this as a (rather lame) attempt at political correctness, it is also a massive shift in attention away from tobacco harm reduction. Reading the statement in its entirety, the new goal is to eliminate nicotine use. Laughable? Absolutely. No government in history has successfully eliminated a substance through coercion or prohibition. Ever. But it’s worse- the very pursuit of this goal may mean the rise of smoking rates after years of decline. 

Sound counterintuitive? Okay. Until recently I would have believed that everyone understood that the dangerous part of smoking is the actual smoking- the combustion, and sucking that into your lungs. But a recent survey conducted indicated that 80% of doctors (with a sample size of 1000 participants) believe that nicotine causes cancer. I think that my audience is smarter than 80% of doctors surveyed but just in case anyone slept through the last couple of decades: nicotine isn’t the thing causing cancer. If we start treating nicotine use and smoking as “same”, we will miss the opportunity to transition people away from cigarettes who don’t want, or aren’t ready, to give up the nicotine. Further, at a time when we can ill afford to squander public trust in government, Health Canada, and our Chief Medical Officers, pursuing a goal that more rightly fits in the category of “ideological” than “medically sound” is really dangerous territory. To be pursuing such a goal in the middle of a pandemic, no less, is downright reckless. 

Let’s look at a few quick facts together. Smoking kills 45,000 Canadians a year. 15% of the population still smokes. The biggest predictor for youth smoking is a parent(s) who smokes. Marginal communities have higher smoking rates. “Proven” methods are  less than 10% effective. The success rate of vaping is markedly ahead of traditional nicotine replacement therapies, nearly double. 50 mg/ml taken by the low power pod-style vaping device is a pretty close simulation to smoking a cigarette, without the combustion and tar. And, taken directly from Health Canada’s site, “Vaping products and e-cigarettes deliver nicotine in a less harmful way than smoking cigarettes.” Why is the government continuing to pick away at the vape file, with so much regulation already in place? Doesn’t the attention seem misplaced?

It is, entirely. But it’s not unusual for the political class to mix a little evidence, a little ideology. While vaping is undeniably magnitudes less harmful than smoking, it does trigger an emotional reaction that is difficult to counter. You can’t soothe feelings with facts. A lot of people, however unreasonably, believe that smokers need to make a clean break with all things tobacco or tobacco adjacent. They know that nicotine is not what causes cancer or other myriad smoking-related health concerns but they blame nicotine for being the driver of smoking because it is indeed the attractive substance in cigarettes. They don’t blame it so much that they can’t accept it in pharmaceutical form: patches, gum, lozenges, etc. But there’s a big difference between those pharmaceutical options and vaping: vaping is enjoyable. 

Of course, it would be. The industry has been user-led. Designed by and for former smokers, with an indie market that has grown up around it, it has even managed to capture the attention of tobacco companies. And therein lies the second problem: tobacco companies have shown an interest. It doesn’t renormalize smoking, as critics have suggested it might. Nor is there any evidence that vaping leads to smoking, quite the opposite. But it does normalize nicotine use, to some extent, and it does permit tobacco companies a path forward. And taken separately or together, those are insurmountable hurdles for a certain number of people. Let’s look at the two issues to see if the risk to 45,000 lives a year is worth dragging them into this war. 

We have, without a doubt, denormalized smoking in Canada. The tactics by which we have done this have sometimes been questionable, some have gone a bridge too far, but only 15% or so of Canadians smoked in 2019. That’s still a substantial number of people (millions would have to quit in order to meet the 5% goal) but it does indicate that smoking is not a widely accepted practice in Canada anymore, compared to 1965 when a whole half of Canadians smoked. One of the arguments against nicotine vaping is that it risks renormalizing smoking, or acting as a gateway. 

If either of these arguments were valid, we would have the data by now. Both tobacco use and electronic cigarette use are monitored in Canada. The one doctor who sounded the alarm when he thought he’d found a link between e-cigarette use and rising smoking rates among youth (and whose work was heavily publicized by the media and relied upon by public health officials as well as legislators) was wrong. His paper was corrected, 13 months after the damage was done, and none of the media channels who promoted the original study had anything to say about it. But there was no increase in smoking. Quite the opposite: smoking rates go down when vaping rates go up. Those arguments out of the way, there is the possibility of normalizing nicotine use.

We ostracize our smokers right now. It’s one of the tactics we used to decrease smoking rates. If we don’t treat people who vape nicotine similarly, won’t their numbers increase? Hopefully. That’s what Public Health England is betting on as they heavily promote the technology as a means to quit smoking. That latter bit is the critical part: PHE hasn’t lost sight of the end goal, to reduce smoking and smoking-related deaths. Hopefully it also means that when a young person takes the decision to (illegally) access a nicotine product of any sort, it’s of the noncombustible sort. We’re not going to eliminate nicotine as a substance, or cigarettes for that matter, by will or by force- we can only drive the market underground. What we want is to normalize the use of nicotine in any of its safer forms. Then we stand a chance at the more attainable goal, of making cigarettes obsolete. But only if something equal or better is in its place: no combination of coercion and wishful thinking and prohibition and finger-wagging will get us there. One need only look to the overdose crisis happening in Canada right now for evidence of that. 

The second point, that vaping may allow tobacco companies a path forward, is just too bitter a pill for some people to swallow. It’s understandable that there is plenty of hatred for the tobacco industry. They have a heinous history and the public health is still suffering for it. The tobacco industry lied and people were not provided with potentially life saving information, “Hey, our products will likely hook and then kill you.” But the revelations about the tobacco industry and their products came out a very long time ago. There are still people who, knowing full well the risks, take up smoking or continue to smoke. If tobacco companies want to put their money and resources into producing or investing in lower risk products, that seems like something we might want to encourage. Assuming that the goal is still to reduce smoking and smoking related deaths. 

There is no new evidence and there are no new reports that would suggest that the government should reexamine the issue of nicotine limits in e-liquids. (Or that they would need to revisit flavours.) That they would do so, at this moment of time, indicates a tone deafness and disconnect that is impressive even for this government. I find it difficult to believe. 

It appears more like part of a coordinated strategy to undermine the vaping industry in Canada, which is largely made up of small businesses and manufacturers with no connection to the tobacco industry. As mentioned at the start of this article, new regulations came into play in January and again in July. There are, yet more, regulations coming into force in January of 2021 that will radically transform the market. Indeed, it changes what products are allowed on the market, eliminating a wide swathe of popular products. And there were regulations before that: staggered and overlapping so that industry can never catch up. The industry is constantly in a state of investing in compliance and then compliance changes again. Before new regulations have even come in, there’s an announcement that more are coming. It is difficult to see this as anything but planned. Referring again to the Statement from the Council of Chief Medical Officers, it is almost as if they are working from a list.

Problem is neither the government, nor our Chief Medical Officers, have ever designed a user friendly option to smoking with twice the success rate of traditional NRTs. That they would meddle– and so enthusiastically– with a technology that they admit shows evidence of “being linked to improved rates of success” is, well, bizarre. (As is their decision that industry is not allowed to make comparative risk statements, like the ones found on Health Canada’s site.) Almost every regulation that they have put in place, or suggested that they are looking to put in place, make or would make vaping products less attractive or less accessible, both to people who currently use the devices and to current smokers. 

That is a serious dereliction of duty. At a time when protecting the public health should be top of mind anything that would undermine it is an affront. If, as is rumoured, the government does proceed with more regulations they should be reminded of our collective focus. The five million smokers and the health of the people who have quit smoking through vaping. They should be pressed to share the risk assessment that they have conducted ahead of making any new decisions and to demonstrate the effectiveness of any new and existing legislation. They should be held to account, with so many lives on the line. And the people who they should first and foremost be accountable to are the people who benefit, or would benefit, from tobacco harm reduction- ahead of everyone else in line and their own ideology.

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