Canada's 'wicked' debate over vaping
'Hope ... but little evidence' that using e-cigarettes helps smokers quit
This is an excerpt from Second Opinion, a weekly roundup of eclectic and under-the-radar health and medical science news emailed to subscribers every Saturday morning. If you haven't subscribed yet, you can do that by clicking here.
The bathroom doors are coming off, students are being hauled into the principal's office and teachers are seizing charging devices in class as the vaping craze sweeps through Canadian schools.
"I would say it is out of control," said George Kourtis, program co-ordinator for health and physical education at the Toronto District School Board.
He recalled the story of one student sent to the principal's office for the third time for vaping. The principal was called away for a moment, leaving the confiscated vape device on the desk.
"He was out of there for 10 seconds and the child picked it up and vaped," said Kourtis. "He asked the child, and he said, 'Sir, it was standing right there, I had to.'"
Stories like that heighten concerns that vaping is creating a new generation of nicotine addiction, even as many hold out hope it will replace cigarettes and stop the ravages of tobacco-related death and disease.
Is it enough to be worried about? You're damned right.- David Hammond, public health professor, University of Waterloo
"It is why it's such a wicked debate that we're having," said David Hammond, a researcher at University of Waterloo, Ontario, who has found evidence that youth vaping in Canada has increased dramatically.
Hammond has discovered another disturbing trend in his data: that cigarette smoking rates among youth are increasing for the first time in decades.
He has shown the research to Health Canada, but it has not yet been published. He is cautious about the finding and is waiting to see if the same result is found in other studies.
"Is it enough to be worried about? You're damned right," he said.
This week, a study in JAMA Network Open found evidence that vaping increases the chances that even low-risk youth will try cigarettes, "raising concerns that e-cigarettes may renormalize smoking behaviours and erode decades of progress in reducing smoking among youths," the study's authors concluded.
- SECOND OPINION | Teen vaping in Canada has taken a 'worrisome' turn
Most of that data was collected before the sleek and powerful nicotine vaping devices Juul and Vype swept the market. Both products are backed by tobacco companies, and both are so effective at mimicking the buzz of cigarette smoking that Hammond believes they might have heightened the risk to youth.
"I think what it has done is bring kids into the market and have them start using these products in a way that starts to look not like experimentation but regular use and potentially signs of dependence and addiction."
Nicotine-addicted teen might try a cigarette
The fear is that a nicotine-addicted teenager who can't access a vape when the cravings start might be easily tempted by a handy cigarette.
"When you don't get that nicotine then the symptoms of craving start to develop," said Dr. Andrew Pipe, a smoking cessation physician at the University of Ottawa Heart Institute.
"You're starting to feel restless. Then gradually symptoms of withdrawal kick in. Now you start to feel physically uncomfortable. You may get a headache, you may become very irritable, and so they go and seek nicotine."
So now what we have is a big mess.- Neil Collishaw, research director, Physicians for a Smoke-Free Canada
All along there has been an assumption that the risk to youth would be balanced by the reduction in adult smoking. But vaping's healthy halo is based more on wishful thinking than on evidence.
"People were proceeding on hope, while I would have preferred a much more cautious approach," said Neil Collishaw, research director at Physicians for a Smoke-Free Canada. "So now what we have is a big mess."
'Hope' without evidence
Vaping products crept into Canada under the radar more than a decade ago as specialty shops began popping up across the country. Until last May it was illegal in Canada to sell a vape product containing nicotine.
"What happened in the interim is they were illegal but tolerated," said Collishaw. "Health Canada did not pursue enforcement of the law. Instead, they changed [the law] and made the products legal — always in the hope, but with very little evidence, that they would help."
Health Canada states on a tip sheet for parents that "vaping is intended to help smokers quit tobacco." But whose "intention" is not clear. So far, no vaping company has applied to Health Canada for approval to market e-cigarettes as a smoking cessation product, like nicotine gum or patches.
And vaping is still not widely used in smoking cessation programs. Doctors hesitate to encourage them in part because they're not certain about what ingredients the various vaping "juices" contain.
"It's a Wild West show in terms of what's in those products," said Pipe.
According to the overall scientific literature on smoking cessation, including new research published in February, e-cigarettes used as part of an intense smoking cessation program work about as well as other methods.
"In all of the cessation supports we have — nicotine replacement therapy, gum, patches, drugs, drugs plus counselling — we are not getting better than 20 per cent," said Prof. Robert Schwartz, a tobacco control researcher at the University of Toronto. "That's because it's so addictive. It's as addictive as heroin."
Using a number of smokers in the U.K. who wanted to quit, researchers assigned one group to use nicotine replacement products including patches and gum, and another group e-cigarettes. After one year, 18 per cent of the e-cigarette users were abstaining from cigarettes, compared to about 10 per cent of the patch and gum users.
But most of the people who used e-cigarettes to quit smoking continued to vape after one year.
"These are smokers who came with the intention of stopping to smoke, so presumably they're highly motivated. If they're highly motivated to quit smoking and at one year they're still vaping, there is concern there," said Schwartz. "They're clearly still addicted to nicotine."
'Bloody difficult addiction'
And in the end most of the smokers kept on smoking.
"It's why we're still talking about people trying to quit smoking one hundred years after we've known it's a problem — because it's a bloody difficult addiction to beat," said Hammond.
So far, the data show that many people who start vaping also continue smoking, creating a whole new class of "dual users."
"Even if you smoke a little bit you are still at risk of major health effects," said Schwartz.
"These products can help some people to get off smoking," said Hammond. "They are not the revolution that some proponents suggest."
To read the entire Second Opinion newsletter every Saturday morning, please subscribe.
- A previous version of this story stated that new research had found e-cigarettes used as part of an intense smoking cessation program work about as well as other methods. In fact, those findings on e-cigarettes are supported by the overall scientific literature on the subject, not just one study.Mar 04, 2019 4:57 PM ET