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Gaston Ostiguy
View Gaston Ostiguy Profile
Gaston Ostiguy
2014-11-06 11:00
Thank you, Mr. Chairman, and thank you very much for the invitation.
I didn't realize that there was such an impressive assembly.
Good morning.
I will be giving my presentation in English, but I believe simultaneous interpretation is available.
I was told I was the only speaker for the first hour. I have material to go beyond my 10-minute limit. If it's too long, you'll just have to stop me. I have lots of material I'd like to go through, if possible.
You can see the damage that is caused by smoking, both in terms of cancer and other non-malignant diseases. You know as well as I do that this year, 2014, is the 50th anniversary of the first surgeon general's report, so it's a great year for smoking cessation and for knowledge on smoking.
Everybody talks about lung cancer related to cigarettes, but there are at least 11 different cancers that are related to tobacco smoking. People very often forget this, and even physicians forget to tell their patients about this. We realize that when something is put in the surgeon general's report, it's usually extremely well documented.
You see on the right-hand side of the slide, the damage caused by tobacco smoking and on the left-hand side you can see the damage that could be related to e-cigarettes. It's addiction. If you have a teenager and he wants to start smoking, what would you tell him to do: use alcohol, marijuana, different drugs, drink beer, or risk getting addicted to nicotine?
Smoking tobacco kills, but nicotine does not. This is very well accepted in the medical milieu. Nicotine doesn't cause cancer. It doesn't cause cardiovascular disease. It doesn't cause pulmonary disease.
When I was more active in clinical practice, we used to see about 200 to 225 lung cancer cases a year. Since the average lifespan of these people is two years, there was a renewal of the clientele quite often. Nicotine causes addiction. When I was a medical student, I was very impressed. In those days, physicians used to go to play golf on Thursday afternoons and the whole hospital was left in our hands. On a nice August Thursday afternoon, between 3:00 and 3:30, I was called to certify the death of three men dying from lung cancer. I said, “This doesn't make any sense. We have to do something about it.”
It would be rather naive to think that all smokers want to stop smoking, that all smokers will be able to stop smoking. When you have a patient who is on welfare because he's lost his job because of cough syncope, and he doesn't have any money to pay for any medication because he's used the 12 weeks of medication paid by the RAMQ, and he goes on the sidewalk and picks up butts of cigarettes to smoke, this is more than a habit, it's an addiction. These people have difficulty stopping smoking.
For some smokers, let's say in palliative care units, is it really worthwhile to stop? I just saw the wife of a patient who's dying of mesothelioma. He is running into difficulty when he smokes within the hospital, but he's going to die within a few weeks. What about the prisons? What about the CHSLD and psychiatric units? Even the best clinical studies at the moment rarely have a success rate of more than 30% during one year.
People realize it's very easy for physicians and health professionals to prescribe a recipe to help people stop smoking, but smokers are not all the same. Some can stop on their own. Lots of them—70% of smokers—over their lifetime will stop smoking cold turkey by themselves. Some others can stop fairly easily with a little help. Minimal intervention and standard pharmacotherapy are usually prescribed.
But in my clinic, the mandate we've been given is to look after hard-core smokers. These people are very addicted. They're referred to us by physicians. They have medical comorbidities, they've tried many times to stop smoking, they haven't been able to, and it's part of their treatment to stop smoking. Very often, these people have other physical and psychiatric comorbidities and other addictions, whether to alcohol, drugs, or marijuana.
The medication we have nowadays doesn't provide the kick that the smoker gets when lighting a tobacco cigarette. Within eight to ten seconds, the nicotine goes to the nicotine receptors in the brain to make the smoker comfortable. The receptors produce an electrical current going to the front part of the brain to produce neurotransmitters, so that the smoker feels great. He feels comfortable because of the serotonin, the dopamine, the monoamine oxidase inhibitors.
We are really trying to approach the smokers individually. Very often, when I lecture on this subject, I have a slide that says “personalize, personalize, personalize”. Even if a smoker tells you that he smokes 20 cigarettes a day, if you measure the creatinine, which is the metabolite of nicotine in the blood, you see how different it can be. It's just like shooting with a 12-calibre gun. You must not approach all the smokers the same way. They have to be approached personally, individually.
At the moment, we have a lot of medications available, in at least three main groups: nicotine replacement therapy; bupropion, which commercially is Zyban; and Champix. But even with these medications....
We are very impressed by the word coming from the Mayo Clinic. They also personalize their approach to the smoking patient, and they and we very often prescribe “off label”, as we call it. You have the inhalers, which provide the patient or smoker with a dose of nicotine much faster than the patch or the gums or the lozenges. We try to approach the sensation the smoker gets when he lights up a cigarette. You see the last one that has been on the market in the next slide on the right-hand side at the bottom: the electronic cigarette, which is certainly the thing that comes closest to the tobacco cigarette in terms of nicotine delivery.
If you want a patient to stop smoking, you have to maintain him in his comfort zone. If you go below that comfort zone, he is going to have cravings and develop withdrawal symptoms. The withdrawal symptoms are numerous and extremely frequent. I don't have the time to go through this, but if you really want to be successful, you have to maintain your smoker in a comfortable zone.
You've probably heard about SNUS, which has been extensively used in Sweden for the last 25 years. It's tobacco in a little pouch that you put inside your mouth, and it delivers nicotine. Sweden has the lowest rate of lung cancer in the world and probably the lowest rate of smokers in the world, at 12%.
This is not new stuff. I was in Alaska last spring. You see in the slide the words, “Give me enough SNUS...and I'll build you a road to Hell”. So it has been on the market, and it has been there for quite a long time.
The next slide shows a picture—you have probably seen them—of the third model of the e-cigarette. At least in Montreal, this is probably the e-cigarette that is used most frequently. The next slide shows the kit that they buy; along with the e-cigarette, it has the electronic hardware and the e-liquid. The e-liquid essentially contains nicotine at different concentrations, plus propylene glycol, vegetal glycerine, and of course also different flavours to make it pleasant.
The patients who have switched to the electronic cigarette have to choose the proper flavour, because some of the flavours are irritating to their throats. When people light up a tobacco cigarette, it is pleasant for them to smoke, so if they want to use the electronic cigarette it also has to be pleasant.
You have different e-cigarettes available, up to the fourth generation, and their use is something that is growing and developing so rapidly that it's even difficult to keep track of what is on the market. I won't insist on this, because it has probably been already shown to you, but this is the battery, the coil, the little electronic piece that lights up the battery, and so on.
As you probably know, the e-cigarette was invented by a Chinese pharmacist in 2003. His father died of lung cancer. It's really a tsunami. In 2013, it has been calculated that there were 7 million users in Europe--1.5 million users in France. There has been a drop in the sale of tobacco cigarettes in France of 7% between December of 2012 and 2013. No medical intervention, no health professional intervention, no program has ever had such a success. It's the same in England and the United States.
The sale of nicotine replacement therapy is going down in England. The e-cigarette is rarely used by those who have never smoked—less than 1% to 1.5%. It increases smoking cessation attempts. They have excellent data coming from Britain and France, and in England it is considered a consumer product.
Facts and factions—this comes from John Britton's paper. Is the e-cigarette safe? This is certainly one of your concerns.The ambient level of nicotine in the expired vapour is 10 times lower than the second-hand smoke from tobacco cigarettes, 3.3 micrograms compared to 31 micrograms. There's no combustion, no CO, and, of course, in our clinics for the patients using the e-cigarette we measure their alveolar CO. It's always below 8 or 9, like you find in the general non-smoking population.
Yesterday, my nurse was a bit surprised because they measured the alveolar CO in a patient who had just had a pulmonary function test. When you do a pulmonary function test, you measure the DLCO, and we use CO to do that. So when she came to the clinic and we measured the alveolar CO. It was higher, it was 12. She was very surprised and very embarrassed by this and she swore that she was not smoking. So you have little tricks like this.
Toxins are well below concentrations in cigarette smoke, 9 to 450 times lower, and sometimes at concentrations comparable to levels found in nicotine replacement therapy, because the nicotine used in the liquid and in nicotine replacement therapy comes from the tobacco leaf and, of course, you are prone to have some impurities and some contaminants. This is why it has to be regulated, but we'll come to that later on.
Is it a gateway to smoking? Is it an incentive for ex-smokers to relapse? At the moment, we don't have any evidence for that, though I must admit that our follow-up hasn't been long enough to provide you with some information about this. But when you read the literature about it, one thing that is very deceptive is the fact that very often they ask kids whether they've tried the e-cigarette. But trying is not necessarily adopting it.
In England, current users in non-smokers represent 0.2%. With regard to children, 98% will never smoke and never try the e-cigarette. Since the advent of the e-cigarette, the percentage of young tobacco smokers keeps falling, from 14% to 12% in the United States and from 43% to 22% in Paris.
What is our experience at the Montreal Chest Hospital, which is part of the McGill University Health Centre? I was working on the site of the University of Montreal before I was asked to work over there. When I was asked, I was given two mandates. There was nobody trying to help the patients of the McGill University Health Centre stop smoking. We covered the Royal Victoria Hospital, the Montreal General Hospital, the Montreal Chest Hospital, even the Jewish General Hospital, St. Mary's, the Montreal Children's Hospital, and the Montreal Neurological Institute.
We don't take any smokers coming from the street, working at Place Ville Marie or Bell Centre and so on. We see people who are ill. They've been told by their doctor that they have to stop smoking. It's part of their treatment. It's very important. These people have tried many times and have been unsuccessful.
We've seen more than 143 people, but these are 143 new patients who have come to our clinic over the last year. They've never been seen before. For these statistics, I have excluded the cases of relapse. Some were seen two or three years ago, and they relapsed to smoking tobacco cigarettes and they're coming back to us.
It's slightly more frequent in females than in males. With 69% of these people it was not recommended necessarily that they use the e-cigarette. We had 31% who wanted to try the e-cigarette. Very often nowadays they come to the clinic and they have already bought the e-cigarette. They come to us to get some information, to know how to use it and so on. In mean age, men are slightly older. The number of cigarettes per day is about the same. We measure the cotinine at the first visit, and it's slightly higher in females than in males. It's better to flag a strong score, to measure the dependency, the addiction to tobacco.
Now if I look specifically at the new patients and relapsing tobacco smokers, there were 69 of these patients who had been referred to us, all hard-core smokers. At the moment, we have 35 who have been totally abstinent from tobacco, and this has been confirmed by the measurement of the alveolar CO and the measurement of the cotinine in the blood. We have 25 dual users of e-cigarettes and tobacco cigarettes, six failures, and three patients who were lost to follow-up, as happens in any type of research.
What kind of comorbidities do we have? There is COPD, and certainly asthma. I work at the Montreal Chest Institute, so it is no surprise that most of our patients suffer from COPD or asthma. We have coronary heart disease, cancer, diabetes, and mental health problems. Very often these people have been admitted for depression. They've been looked after by a psychiatrist. They are still taking psychoactive drugs. It's very frequent in this population.
Among the dual users, 8 out of 25 people were smoking more than 30 cigarettes per day at their first visit, and we had a champion who was smoking 75 cigarettes per day. This guy now has been given his diploma for being one year abstinent. He doesn't smoke any cigarettes anymore. These people have tried to stop smoking six times on average, and 8 out of 25 patients are very often down to two to three tobacco cigarettes per day. We would call that harm reduction.
Despite the controversies, it is clear that the electronic cigarette is far less hazardous than tobacco cigarettes. Smokers smoke primarily for the nicotine, but they die primarily from the tar, combustion of tobacco.
What advice should a clinician—because I deal with my colleagues—give to their patients? E-cigarettes are still not our first approach. We encourage all smokers to quite smoking by using evidence-based medicine and behavioural support in the first instance.
There are two basic principles to help people stop smoking: pharmacotherapy and counselling. It's lifestyle. If they had adequate trials of the standard quit-smoking approach and failed to remain abstinent after many attempts, we suggest that they try the e-cigarette, ideally in conjunction with behavioural support. When we enrol a patient in our clinic, he's followed for at least 12 months.
There is an urgent need to regulate e-cigarettes because consumers need to know what they're buying, and whether they're buying a good product. We have no way at the moment to know this.
It's also urgent because as one of my colleagues, Dr. Juneau, at the Montreal Heart Institute, says, “If I see a patient admitted for myocardial infarction, and I tell him he should try..., he answers, 'Well, after five or six times I haven't been successful. Please, Doctor, don't bother me with this.'” We know that if a patient with myocardial infarction stops smoking, his risk of having another cardiac accident is diminished by 50%.
If we look at COPD patients, we know that if they do stop smoking tobacco cigarettes, it will reduce hospital admissions by 40% and visits to the emergency department by 40%. It's great for them, for their health, but it's also great for the finances of the medical programs. A lot of money could be saved by this.
Also, e-cigarettes need to be properly labelled with proper warnings: childproof bottles, graduated bottles, or graduated e-cigarette reservoirs. Some of them are available now on the market, but most of them are not. When we ask the patient what the concentration of nicotine is in his e-liquid and how many millilitres he is using, very often it's difficult for him to tell us. You could easily transfer or calculate how many cigarettes it would correspond to.
Of course, it should be taxed just like the tobacco products. But it should be sold in specialized, accredited shops—not everywhere, not in the depanneur, not in the gas station. Because it is not that user-friendly. Especially people with less education, who are getting older, have difficulty learning how to use it properly. This is our experience. We have very many patients who come to the clinic, who don't use their e-cigarette properly because they don't know how to use it. They know how to fill the reservoir and so on. They don't know how to calculate the number of millilitres of liquid they're using. They have to be trained how to use it.
We should also provide a large range of nicotine concentration. The European Union suggests not to deliver more than 20 milligrams per millilitre of nicotine. As you saw, if somebody has nicotine in his blood of 700, it's not 20 milligrams per millilitre in his e-liquid that is going to keep him in his comfort zone.
Keep the flavours, but not flavours attractive to children. One of the reasons that the e-cigarettes are successful is because they taste good. When people smoke tobacco cigarettes it's also because they taste good.
It should be allowed in certain public places, such as prisons, palliative care units. Allow exhibits in specialized shops and instructions to users. Also, we should promote it as a harm reduction tool.
This thing is growing up so fast. This is one of the latest e-cigarettes. It looks very much like a package of cigarettes. If you open it, you get a little gadget that will allow you to inhale nicotine. The owner of this new electronic cigarette is British American Tobacco.
Of course, probably many of you have these new machines for coffee. This is the Ploom. It looks very much like the stuff you use to make your tobacco in the morning. This is going to be very popular also.
In conclusion, e-cigarettes can save many thousands of lives. It's been calculated to save 6,000 lives per year in Great Britain, 430,000 per year in the States, and 800,000 per year in China. It has to be regulated, but its availability must not be made more difficult than buying tobacco cigarettes in any depanneur or gas station.
Mr. Chairman, if people want information, I have never seen any books written on e-cigarettes in English, but there are two publications in French that can provide you with lots of information on e-cigarettes. They're written by chest physicians or specialists in smoking cessation.
Thank you very much for your attention.
View Dany Morin Profile
Very good.
You said there were three types of smokers. Can all three benefit equally from e-cigarettes?
Gaston Ostiguy
View Gaston Ostiguy Profile
Gaston Ostiguy
2014-11-06 11:28
Many people are able to quit cold turkey, in other words, overnight without any medication. Patients are asked whether they smoke, and they say no. They are then asked whether they used to smoke, and if so, how long ago they quit. These types of smokers tell us that they quit overnight, just like that, 25 years ago.
They do not see a doctor for help quitting. They just quit like that. Figures show that, over a lifetime, about 70% of smokers will quit.
View Eve Adams Profile
Lib. (ON)
Doctor, you made some recommendations that if e-cigarettes were to be regulated in Canada you would recommend that there be some gradients on the e-cigarette itself so that people can understand how many cigarettes they're smoking. What level of nicotine and what other recommendations would you have to offer?
Gaston Ostiguy
View Gaston Ostiguy Profile
Gaston Ostiguy
2014-11-06 11:36
Again, when you see a smoker, of course you evaluate him and you ask him how many cigarettes he smokes. To give you a proper idea of the number of cigarettes he smokes, we measure his alveolar CO. If somebody comes out of the clinic with CO of 12 ppm or 18 ppm he will not be given the same concentration as somebody who comes in with 45 ppm CO in his alveolar air. You know that from the rules in the workman's compensation board, if you go over 50 ppm in a shop the CSST would close the shop.
View Eve Adams Profile
Lib. (ON)
Are you suggesting doctors serve a parallel system then, where somebody would come in and meet with their physician regularly and under the advice and monitoring of their physician they would end up eliminating their addiction to nicotine, and then there would be a separate parallel system where e-cigarettes would be available at specialty shops as you mentioned or as readily available as cigarettes currently are in convenience stores?
Gaston Ostiguy
View Gaston Ostiguy Profile
Gaston Ostiguy
2014-11-06 11:36
Well, of course, in our experience we use it to help people to stop smoking and for harm reduction. But again, tobacco cigarettes have been on the market for years and no new government has ever been able to ban the sale of these cigarettes. I think that nobody thinks it's going to be possible. So tobacco cigarettes are always going to be there.
If we have to be realistic and say that you will always have a certain number of smokers in the country, it is certainly going to be less harmful for them to use the e-cigarette than the tobacco cigarette because nicotine, like I said, is not harmful to your health. I mean, is it really worse than coffee? Are you going to close all the Tim Hortons shops? Probably in terms of physical effects on your cardiovascular system it's not much different from coffee and nowadays you see everybody coming to work with a cup of coffee in their hands and we don't care about this, really, at the moment.
Gopal Bhatnagar
View Gopal Bhatnagar Profile
Gopal Bhatnagar
2014-11-06 12:06
Thank you very much.
It's certainly a pleasure to be here in front of this committee. Thank you very much for the opportunity.
I'll open by saying it's a privilege to be here because of a number of things. Coming up the street in a taxi, as an ex-serviceman and a father of a reservist, I had the opportunity to see in front of me that memorial. It was a very emotional experience. In addition, it's the week coming up to Remembrance Day. In fact, it reminds everybody that today in 1917 our Canadian soldiers took Passchendaele.
With that, I'll try to emphasize the same passion in my knowledge and support for e-cigarettes, and be happy to answer your questions.
I will tell you a little bit about myself. I'm not new to safety or innovation. I established a community cardiac surgery-based practice in Canada. We're now one of the three largest beating-heart surgery centres in North America, meaning we don't stop the heart-lung machine. We did that specifically to improve patient care, and we are lead benchmarks for surgery. I was chief of staff at our hospital, so having to look out for people who could not look out for themselves has been a great passion of mine.
After six months of research, I'll declare that I did find an e-cigarette retailer, but I also advise people to have heart surgery and am renumerated for it. In fact, every physician is remunerated for recommending their treatments, and I would not at all be involved in or stand in front of you to create any kind of bias. I would be happy to address any questions you may have in that regard.
In fact, this is the enemy. The smoking I see every day clogs arteries. That's what I make my living out of. It causes lung cancer.
This slide shows an individual in her last stages of palliative care, and we need to stop this. Of what you see in front of you, 85% to 90% can be prevented.
This slide shows the leading causes of lung cancer: smoking; radon gas we've been able to get rid of; asbestos we regulate and get rid of; air pollution. Air pollution is out there. It's not safe to breathe in our cities.
I want to address clearly some fundamentals of the safety of e-cigarettes for users. No adverse health outcomes were seen when primates were exposed to continuous high concentrations of polyglycol vapour. The primates and mice were put in a box and were given high concentrations to breathe for 12 to 18 months. Histological samples of the lungs were taken and we could find no chronic effects or changes in those lungs in the deep alveolar tissue.
When smokers are able to go off tobacco smoke, they experience immediate beneficial effects.
On pulmonary inflammatory disease, I tell my smoking patients they have to stop smoking two weeks before surgery. The risk of infections is far less because the immune system of the lung improves as soon as we get people off cigarettes, aside from it simply being a long-term cancer-causing agent.
I'm going to use some terms. I want to talk about cytotoxicity, and that's the potential to cause harm or cancer.
Essentially you take the liquids, you take your chemical, you put them on cell cultures and you study them under the microscope to see if there's any change in their DNA. Does it damage the cells in any way? What we see is that when you actually apply the polyglycol vapour, or e-liquid vapour, you see no cytotoxic changes to those cells. These can be fetal cells. They can be stem cells. So you can place it directly on these cell cultures without any effect.
If you do the same thing with extracts from tobacco, even down to a 5% solution of tobacco extract, it causes mutations in the genes of those cells.
In terms of the safety for bystanders, remember that a regular cigarette burns at the end. If you're sitting there and you're a bystander, you're getting the direct effect of that. Any vapour that's inhaled from an electronic vaporizer is first absorbed into the user. What comes out is what's left after absorption, and it's typically just a polyglycol vapour. There are very small amounts of nicotine in it. There have been studies that have shown bystanders will be exposed to nicotine. If you actually take a look at the way those studies were done, it was vaporized into a box. Essentially, to put it into context, you would have to lick the entire inside of the box to get any meaningful amount of nicotine, if you're a bystander.
If you take a look at heavy metals that can be possibly produced in it, they are detectable but are less than 1% of threshold values that you would consider safe if you were to walk into any factory or workplace today. And that's for the user. The bystanders are going to get even less.
I only put up this slide to simply show you there is no mystery around what's in vapour.
Chemical chromatography, liquid chromatography...we can identify all the chemicals that are in there. It's not a mystery. We know that every one of those chemicals, if they exist or are detectable at all, exist at threshold levels that are well below occupational health and safety standards, even if you provide a factor of 10 as a safety margin. This slide shows the same.
This slide compares Nicorette inhaler mist compared to that found in electronic cigarettes. We can see that if you were worried about formaldehyde—a lot was made about formaldehyde—the original FDA trial said there's formaldehyde in it....
There was a question earlier on in the session about the temperature of vaporizers. E-cigarettes vaporize at about 60 degrees. If you vaporize polyglycol at 280°C, in fact you burn it, you will create trace amounts of formaldehyde. An electronic device is incapable of creating that temperature. What we see is a profile of toxicity that's similar to something that's already approved today, that being the nicotine mist vaporiser.
Our youth are very important. I have kids. I don't want them to be exposed to anything toxic. I don't want it in our schools either. But what's the reality? If you take a look, unfortunately, kids somehow get cigarettes. They're banned and they're not supposed to get them, but still they do. We see, shockingly enough, as I was telling my son, that one in 100 of kids in grades 6 to 9 smokes cigarettes. Where do they get them from? We know that by the time they're teenagers, we have rates as high as 14% of kids who are not supposed to have tobacco in their hands or have it available, but somehow they get it. So for me the issue is, why are 14% of our kids smoking?
If we take a look at the United States, the current user prevalence in U.S. adolescents, have a look here, if you take a look at e-cigarettes only, up to about 25% is a very small part. Most are in fact dual users of the ones who use electronic cigarettes.
This study was performed in the United States and it shows a drop in smoking rates. If you take the top and you say, well, the use of electronic cigarettes has doubled. We see young people walking around with electronic cigarettes, it's an epidemic. But, in fact, if you take a look at it, very few of them are using e-cigarettes only. Almost all of them, 99% of them, are previous smokers. When I look at a slide like this, yes, I can worry about the 0.6%, or I can really be dreadfully afraid of that 11.8%, because if you started smoking as an adolescent, your profile of getting emphysema, lung cancer, and heart disease, is huge over your lifetime.
With regard to nicotine safety, nicotine is an alkaloid. It's found in plants. It's made in their roots. You can find it in eggplants, tomatoes, black peppers; it's in the highest concentration in tobacco. Why does tobacco actually have nicotine? It's an insecticide. It protects the tobacco plant from being eaten by insects, so that's why in days gone by high doses of nicotine were used as an insecticide. In fact, a question was raised about the toxicity of nicotine. In industrial-available strength, nicotine is toxic. It will cause seizures and vomiting, and it can be lethal. Outside of an industrial factory, those concentrations of nicotine are not available.
It does not cause cancer. It can be addictive, but there are no serious health care outcomes related to nicotine alone in the concentrations that are available today. Much is made about a child eating or drinking nicotine. Most likely if that happens, they will vomit. It is not fatal. They will vomit even if they like the flavour. They will take it, it will irritate, and they will vomit.
With regard to nicotine safety compared to analgesics, liquids, cosmetics, vitamins, there are very few—618—annualized calls to poison control centres, compared to over 200,000 calls for something like cleaning liquids and cosmetics.
On nicotine as a gateway to other drugs, the Polish study was mentioned. However, in a huge U.K. study as well, and if you take a look in Germany, the number of electronic cigarette users as a percentage is always around 0.1% in youth. There's no molecular mechanism or clinical mechanism, aside from a very small Polish study, that would indicate that people will start with electronic cigarettes and move on to something else.
I want to emphasize that.
Smoking rates have gone down very consistently since marketing has been started to counteract tobacco advertising. But we've plateaued. In fact, now we're in the endgame for a tobacco-free society. That's where I certainly echo the sentiment of physician members and committee members. I would like to see a tobacco-free society. How can we let this occur? We've got the low-hanging fruit. The people we could get off tobacco, we've gotten off tobacco by every means. What's going to get us down to 0%?
Much is made about smoking cessation. The ITC studies say that people who incorporate electronic cigarettes in their regime cut back their exposure to cigarette smoking from about 20 to about 16. It's helpful in reducing emphysema, cancer, heart cessation rates because it's a dose-dependent phenomenon. The more tobacco you take, the worse it is. So you don't have to go from up here to zero; coming down on the scale is beneficial. We can see here, lung cancer in men, cigarette consumption in men. The more you smoke, the worse it is. You move people down that scale, you lower their risk.
Once again, I want to emphasize a lot: tobacco harm reduction. Cessation is an all-or-nothing phenomenon. Tobacco harm is proportional.
This is a great slide. I draw your attention to it. The fact is, if you can reduce people's cigarette consumption, you reduce their relative risk almost exponentially. Take a look at people taking a pack a day in that pink bar. You get them down to 10 cigarettes a day and the trials, both Burstyn and Polosa, have shown that you can reduce cigarette consumption by about 50%. So you're taking people down into that very low column. Are they at a higher risk than zero? Unfortunately they still are. But you've reduced their risk twofold.
In smoking cessation therapy, we can take a look at e-cigarettes and they have gone up. There's a reason they've gone up. Despite all the thinking that experts have, we have failed smokers in being able to get them off cigarettes. We can applaud ourselves about our medical therapy, about our pharmacology, about our drugs, but one in five Canadians still continues to smoke.
I would congratulate you on many respects but one is that you have undertaken more due diligence at this committee than has been done by the FDA, by the World Health Organization, and by the CDC. None of those august organizations that many of the population depends on for clear and accurate information undertook this level of diligence. When you read statements from the World Health Organization, the FDA, and the CDC, those decisions were made behind closed doors. Their review process was not transparent at all. I don't really understand why they say what they did. On the re-normalization of smoking, the gateway phenomenon was attributed to Mark Frieden. He is the director of the FDA. I don't know why he believed that. I have no idea why he made those statements but he did. Because he's director of the FDA, everybody puts credence on that.
I'd like to conclude. I know I'm running short on time. I don't want to take any time from my august member here. So, available cytotoxic and chemical analysis shows e-cigarettes have a risk profile that is orders of magnitude less than traditional combustible. Nicotine does not cause cancer. Tobacco kills people. There's no evidence on a molecular level from the New England Journal of Medicine or epidemiological studies aside from only one that e-cigarettes are a gateway to progressive use of worse substances. Tobacco use in our youth remains the concern. In fact, the presence of e-cigarettes could be argued to be reducing the use of combustible products. Flavoured cigarettes, although they have been available in Europe for a decade...still only .1% of all e-cigarette users are youth.
Research indicates that second-hand vaping is not a concern.
My suggestions are—I'll run through these; I believe we can all read—that a new category of tobacco harm reduction tools should be created because we cannot predict the future. Let's create a regulatory and structural framework where we can continue to evaluate new products and tools as they come along.
We certainly need to have manufacturing standards for hardware, the battery composition and duration, and you need to establish standards for your liquids. People cannot be making this stuff up in their garage. That's not what we want. We need manufacturing facility requirements. We need labelling. I believe that nicotine can potentially be toxic in high concentrations. We need a lot of tracking mechanisms to know about product recalls and ingredient quality. Certainly, they need to be bottled in a way that it's as difficult as possible for children to get at it. Restricting the sales and products, I think we've been over that.
There is some sort of statutory warning perhaps for women who may be pregnant because there might be some effect on very early fetal cell tissues. In principle, I think there should be some advantage to using electronic cigarettes financially and socially over using a traditional cigarette. I'm not going to suggest exactly how that is. Any type of lifestyle advertising should be banned. I believe that it should be promoted as a tobacco harm reduction strategy. Much has been made on the sale of youth flavours. I'll leave that and answer that during the time for questions, but it should be based on consumer demand.
Increase taxation of tobacco products if we think we're going to lose taxes by the use of tobacco products. Make it more expensive to use whatever tobacco products there are out there, but give some incremental advantage. I believe that the same health care organizations that are saying that there's insufficient evidence should be charged with funding unbiased brand-neutral trials. A standing committee of tobacco harm reduction should be part of the health protection board, that I have occasion to deal with and have helped me to treat a great many patients over the years.
Thank you very much for your attention.
David Sweanor
View David Sweanor Profile
David Sweanor
2014-11-06 12:23
Thank you very much. It's a pleasure to be here.
I'm a lawyer. I've spent now over 30 years working on public health policies on tobacco in Canada and around the world. I've testified in front of quite a few committees over the years and I think it's fair to say we've literally made history on other issues of tobacco in Canada.
When I first got involved in the beginning of the eighties among 15-year-olds to 19-year-olds, 42% in Canada were daily smokers, and in the space of 10 years we got that down to 16%. That was policy. We led the way on using things like tax policy, advertising restrictions, package health warnings, smoke-free spaces. A few people now remember we were the first country to get smoking out of airplanes. Now many of us have trouble even remembering how awful that used to be, but it was because of things like this.
And I must say, at a personal level, it's fair to blame my wife on some of this because as I was a young lawyer starting out, deciding I was going to change the world, she was a young doctor, and she was talking about how many people were sick, how many people were in hospital beds because of smoking. And at one point I said, “Well, if smoking is as big a problem as doctors say it is, you ought to be doing more about it.” She said, and she's usually right, “You don't get it.” And this was not the only time in our relationship she said that. “Figuring out why people are getting sick is a medical-scientific problem. Dealing with it is a social-legal-political problem. It's up to lawyers and politicians to deal with it.” And I think she's right, and I've been spending over 30 years trying to deal with it. And that's why I think we're here today.
We have had these great successes. We've reduced per capita consumption of cigarettes in Canada very dramatically over that 30 years, probably by about two-thirds. But because of an increase in population and the fact that a lot of people reduced, but didn't quit their smoking, the total number of smokers in this country went from just over seven million to somewhere around five million. It's still our leading cause of preventable death.
I have no written submission for the committee, but what I'd highly recommend is that Clive Bates, who was to testify here, has sent in a very good submission. I think Clive, who is a friend and a colleague for many years out of the U.K., is one of the best thinkers we have in public health on tobacco. And instead of reading anything that I would submit, I suggest you read what Clive submitted twice. It's that valuable.
If the committee is interested, I can certainly submit other things that I've written over my career, including on this topic. I should also say that I have no financial conflicts of interest. I don't get money from anybody on any side of this, whether it be people trying to sell the products or people trying to oppose the products.
Why are these things important? Why is it we're talking about them? Well, frankly, it's because cigarette smoking is still by far our leading cause of preventable death. It's still killing somewhere in excess of 40,000 Canadians per year. Based on the status quo, if we simply continued to do the things that we're doing now, we can expect another million deaths in the next 25 years. Those are all totally preventable. We can do something about it.
And one of the really odd things that I've experienced in my career working on this is that we have done all sorts of things about the periphery of the cigarette, but not dealt with the cigarette itself. We've not dealt with the fundamental problem. We've talked about things like what price because of taxes you have to pay, where you can buy it, who can buy it and who can sell it, where you can use it, what sort of labels you need to have on it, and what sort of advertising there will be for it.
But the product itself is the fundamental problem because cigarettes are just an incredibly deadly delivery system for a drug. If people got their caffeine by smoking tea leaves, it would also be killing a tremendous number of Canadians because essentially, it's the smoke. As you've heard from others, we know that smokers smoke for the nicotine, they die from the smoke, and the public health tragedy is that they don't need to. Even if they were going to use nicotine, they can use nicotine in a way that simply doesn't cause those problems. As I've been saying, we haven't worried a whole lot about people drinking tea and coffee. It can be addictive; there are risks. It's low enough that we don't worry much about it. If they were smoking coffee beans, smoking tea leaves, it would also be a huge problem.
We've known for decades that we could reduce the problem. We could essentially eliminate the problems by simply getting rid of combustion-based delivery. And we now have products that are coming onto the market that provide that sort of opportunity.
Wells Fargo, the giant investment bank, has estimated, and their belief is, that within a decade electronic cigarettes will outsell cigarettes in the United States, depending what sort of regulation facilitates or gets in the way of that happening. That's a huge opportunity.
What we're seeing here is something that I think follows the history of what we've seen in other areas of public health, whereby we're getting an intervention that isn't a medical intervention per se; it isn't because of government or health departments telling people what to do. This is coming from entrepreneurs who come out with a product to meet a demand from consumers who are saying, I don't want to smoke; I want something that will help me get off smoking.
People are incentivized to come out with better products. Among other things, people are spending $700 billion a year buying cigarettes around the world. Most of those people don't want them.
This is similar to what we've seen before. In the early 1940s, the leading cause of cancer death in Canada wasn't lung cancer, which is by far our biggest problem now; it was stomach cancer. Stomach cancer deaths fell precipitously, and they fell not because of a hugely expensive government intervention; they fell because entrepreneurs leveraged innovative technology to meet a consumer demand—for refrigerators. We used refrigeration; diets changed; stomach cancer rates plummeted.
Look at what happened with automobile death rates. When I was young.... I think all of us growing up, certainly in small-town and rural areas, can name lots of friends who died in car accidents. More than 6,000 Canadians were dying each year. It's fewer than 2,000 now, even though there are more than twice as many cars on the road. We changed the delivery system; we changed the product; consumers were able to access something; entrepreneurs were incentivized to come out with better auto safety features. The death rates are down by more than 80%.
When we look at nicotine, we could do something that would lower the death rates far more dramatically and far more quickly, and we simply have to figure out how to seize that opportunity. How do we de-normalize smoking? That's what these products can do; they are a fundamental threat to the cigarette status quo.
It's very hard to imagine somebody now wanting to get into a car that doesn't have air bags, seatbelts, safety glass, etc. It's very hard to imagine somebody wanting to buy the snake oil medicines that existed in the 1930s now, rather than modern medicines.
We have the ability to give a real option to smokers, and in doing that we have the potential to then use the tools we've been using to try to reduce smoking—regulation, litigation, etc—to further change the market. I think we have the potential to make cigarettes history; to make one of the biggest breakthroughs we've ever had in public health.
In terms of how we do this, a key thing is to identify what not to do, because I think we've been seeing a lot of that. I don't think we need to engage in moral panics; I don't think we need fearmongering; I don't think we need people hyping potential, minor, hypothetical, and containable risks; I don't think we want to use regulation that protects the cigarette business because of some fear that something might go wrong with products that are massively less hazardous. We have to be aware that the unintended consequences people worry about have to be seen in relation to the 40,000 deaths a year by cigarettes.
That's the problem. How are we going to avoid being held responsible in future years for having maintained that epidemic when we had the option to do something about it.
What should we do?
I think we need fit-for-purpose regulation. There's a tendency for people to look at the regulations we now have on nicotine and say that it has to be a medicine or it has to be a tobacco product. It isn't either of those. Just as, when somebody says “sort these blocks into squares and circles” and then hands you a triangle, it's important to say “I need another pile; this isn't either of those”, we need to look at regulation that is aimed at getting the most effective measures in place to move smokers off combustion-based delivery and get people on to not just the e-cigarettes that exist now, but to wherever innovation will take us.
We have, even here in Canada, leading medical researchers who are developing what I think are phenomenal products—products that could be far more effective at getting people off cigarettes but that are stymied by regulations—saying, we can't market them in Canada; the barriers to getting these things into the market are simply too great. We need regulation that opens up the opportunity to do things such as that.
We need to have truthful, non-misleading information to consumers. The history of public health tells us that often the biggest breakthroughs are based on two very simple concepts. One is that you give people enough information to make an informed decision; and two, you give them the ability to act on that information. If we do that, amazing things happen when people are able to act.
Look around at what is now happening with electronic cigarettes. As you've heard from other speakers, in the U.K. the anti-smoking groups there estimate that more than 700,000 smokers have totally switched to electronic cigarettes. There are higher numbers in France.
In the U.S., with the best numbers I can see, over two million have already switched entirely to these products. These are huge potential breakthroughs, but it's very much the general patent line, “there's no such thing as an obstacle, only a new opportunity”. Rather than looking at this and asking what might go wrong, let's think of what might go right. What could we do that brings us within the realm of what we've had a history of doing in Canada, of getting public health right and setting precedents here that save the lives of a heck of a lot of Canadians and that are then exportable to the rest of the world as good public policy?
Thank you.
View Wladyslaw Lizon Profile
Thank you very much.
The next question, through you, Mr. Chair, is for Mr. Khara.
You did say that people use e-cigarettes if they want to quit smoking. Now, from your practice, or maybe from some studies, how effective is it for smokers? Do they do it individually? Do they go to therapy that someone designs? How effective is that process?
Milan Khara
View Milan Khara Profile
Milan Khara
2014-11-04 12:15
If the question is “how effective are electronic cigarettes as a cessation device?”, that's again a slightly complex answer, because there's a lot of anecdotal evidence. A lot of people will tell you that they have used electronic cigarettes to quit smoking. A lot of online surveys will also report that people are using electronic cigarettes to quit smoking, but if you look at trials that have compared electronic cigarettes to other evidence-based treatments to help people quit smoking, there's very little available.
Probably really only one randomized control trial of any rigour has been done, a New Zealand trial that suggested that electronic cigarettes were about as effective as a nicotine patch, but in that trial, both nicotine patches and electronic cigarettes were actually not very effective. But that's one trial and, for perspective, we can look at the thousands of trials that have shown that nicotine replacement therapies—patches, gum, and those kinds of treatments—are quite effective in doubling and maybe even almost trebling the likelihood of success.
I would suggest that there's an evidence gap even though there are some lower levels of evidence that electronic cigarettes can be helpful. The big thing that I think overlies all of this is that people like electronic cigarettes and people want to use electronic cigarettes. There is rapid growth in the use of these products, not in the way that nicotine replacement therapy is viewed, which is viewed with some lack of enthusiasm by people who are looking for an answer.
To answer your question, we don't really know how effective these devices are. That evidence is emerging.
View James Lunney Profile
Ind. (BC)
In terms of re-normalization, we know there's a whole psychological and neurological phenomena associated with smoking. It's timing—after eating—and it's the mechanics of what to do with your hands and so on. For many smokers, the great successes we've made have been because of the restrictions we've brought in on where you can smoke, on smoke-free areas and so on. It's like a get-out-of-jail-free card with regard to the social stigma for many smokers who might be on the verge of quitting or who are now having a great opportunity to switch, when they have trouble smoking, to a "vaping" program. Is that not going to help them perpetuate their problem rather than break the habit they might be on the verge of quitting?
Peter Selby
View Peter Selby Profile
Peter Selby
2014-10-28 11:54
There are two ways to look at that. One is, when they start doing dual use, is that actually an exit strategy from cigarettes completely or is it a stable state? We don't have the science to suggest what it is, but we do have something to point to. As shown in a study by my colleague, Robert West, in the U.K., who I think is presenting to you, if you look at a population, you will see that before they make that attempt at quitting, often the population will have started reducing their cigarette use before they quit. So anything that can help people to reduce.... Generally, we need to study to see if it actually translates into quitting. The unanswered question with e-cigarettes is whether it becomes, as you rightly pointed out, a matter of, “I will smoke when I can, and when I can't smoke, I'll vape”.
It's a great unanswered question right now.
View Matthew Kellway Profile
Thank you very much, Mr. Chair.
And thank you, gentlemen, for joining us today.
You provided us with a lot of information in a very brief time.
If I could start with a bit of clarification, Dr. Peruga, your comments are with respect to electronic cigarettes that contain nicotine, I presume. Is that the case? Is that what you were dealing with entirely in your comments?
Armando Peruga
View Armando Peruga Profile
Armando Peruga
2014-10-28 12:22
No, sir. They are with respect to those that contain nicotine as well as those that don't contain nicotine.
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