Thank you, Mr. Chairman, and thank you very much for the invitation.
I didn't realize that there was such an impressive assembly.
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.