E-cigarette use in Canada today

Approximately 20% of Canadian teens aged 15 to 19 report having tried e-cigarettes, but does the use of e-cigarettes increase their likelihood of becoming smokers of traditional cigarettes? That was the question that Canadian researchers set out to answer in a study published in the Canadian Medical Association Journal in October 2017.¹

Collecting data from over 19,000 students in grades 9 through 12 across 89 schools in Ontario and Alberta, researchers polled participants to ask them about their smoking habits in 2013 to 2014 and again one year later. Students were asked about their cigarette use over the prior 30 days and responses were categorized into the following six levels of use: daily, less than one per day, prior use but abstinent in the last 30 days, “experimental” (had smoked an entire cigarette), “puffers” (had tried but not finished a cigarette), and lifetime non-smokers. Approximately 10% of the teens indicated they had used an e-cigarette in the 30 days leading up to the survey.¹

The study demonstrated that between 2013 and the follow up interviews in 2015 the prevalence of e-cigarette use increased from 7.2% to 9.7% whereas tobacco use dropped from 11.4% to 10.8%. However, among students who had never smoked on the first round of interviews, 8.4% reported smoking a cigarette by 2015. Overall, students who reported using e-cigarettes in the 30 days prior to the 2013 interview were found to be more likely to have taken up cigarette smoking and to have smoked on a daily basis by the time of the follow up interview.¹

However, additional research needs to be done in order to determine whether or not there is a cause and effect relationship. Do e-cigarettes initiate smoking or did the survey just identify at an earlier age those more likely to take up the habit?

The federal government is responding to concerns about the relationship between tobacco and e-cigarette use and smoking rates among teens with Bill S-5. This act, designed to make vaping products legally available to Canadians over the age of 18, will prohibit selling to minors. The government has said the legislation will support its goal of working to reduce tobacco use in Canada from 15% in 2015 to less than 5% by 2035.

With respect to Canadian youth, Bill Blair, Parliamentary Secretary to the Minister of Justice and Attorney General and to the Minister of Health, has described the bill as a tool to strengthen measures preventing teens from accessing both vaping and conventional tobacco products by banning sales via vending machines and requiring proof of age at point of sale or of delivery for products purchased online. Vendors who sell to minors can face fines of $3,000 for a first time conviction or up to $50,000 for a subsequent offense.³

Bill S-5 also bans the promotion of flavour ingredients which are thought to be targeted to younger users. This includes confectionary or soft drink flavours.

Critics argue that vaping provides a safe alternative to tobacco. Is this the case? It may be too soon to tell but a number of researchers and academics are starting to weigh in.

The Centers for Disease Control’s position is that e-cigarettes have the potential to benefit adult smokers if used as a complete substitute for smoked tobacco products. However, they do not consider them safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.⁴

According to the Canadian Medical Association’s position statement, in the absence of solid evidence of harms or benefits, the sale of e-cigarettes containing nicotine should continue to be banned in Canada and all e-cigarette sales should be banned for Canadians younger than the minimum age for tobacco consumption.⁵

A recent comprehensive review by the National Academies of Sciences, Engineering and Medicine in the United States investigated the health impacts of e-cigarette use. They conclude that because e-cigarettes have only been in the U.S. market since 2006 it is still too early to compare their health effects to those of combustible tobacco products. However, they were still able to draw some interim conclusions, including:

 

• There is conclusive evidence that the exposure to nicotine and other potentially toxic substances from an e-cigarette is highly variable and depends on product characteristics and how the device is operated.
• There is substantial evidence that some chemicals present in e-cigarette aerosols are capable of causing DNA damage. Whether or not the level of exposure is significant enough to contribute to human carcinogenesis is undetermined.
• There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans.
• There is limited evidence that e-cigarette use is associated with short-term increase in systolic blood pressure, changes in biomarkers or oxidative stress, increased endothelial dysfunction and arterial stiffness, and autonomic control. However, there is insufficient evidence that e-cigarette use can be associated with long-term changes in heart rate, blood pressure, and cardiac geometry and function.
• There is no available evidence whether or not e-cigarette use is associated with clinical CAD, stroke, or peripheral vascular disease.

The impact of e-cigarettes on Canadians’ long-term health and wellbeing remains to be seen. While it’s heartening to see incremental reductions in tobacco use, substituting e-cigarettes for tobacco may not be the panacea that some users hoped for.

Evidence as to whether e-cigarettes lead to combustible cigarette smoking in youths is not conclusive, but Bill S-5 has received Royal Assent and will soon become law. As further studies are released, underwriters should continue to monitor e-cigarette smoking habits and stay abreast of updates.

 

References
1. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. David Hammnd PhD, Jessica L. Reid MSc, Adam G. Cole MSc, Scott T. Leatherdale Phd
2. Library of Parliament Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts, Publication No. 42-1-S5-E 
3. www.cdc.gov/tobacco/basic_information/e-cigarettes
4. CMA.ca
5. Public health consequences of e-cigarettes, conclusions by outcome. The National Academies of Sciences, Engineering, Medicine, nationalacademies.org/eCigHealthEffects