Tuesday, 17 September 2019

One week into the Canadian election, JUUL launches a political action campaign.

Tomorrow, the Canadian election campaign official enters its 2nd week. So far the focus has been on traditional voter issues -- jobs, the environment, taxes, etc.

But in the wake of the (now seven) recent deaths of young American vapers, the media has asked federal leaders whether they will follow the example of U.S. governments and put more restrictions on the marketing of vaping products. The response was a decided non-committal.

Is it a coincidence that in my e-mail today was an invitation from JUUL to "protect my vapour access" by becoming an "advocate for reasonable policies that protect adult access to vapour products to encourage them to make the switch from combustible cigarettes."? (As a keenly interested party, I had subscribed to their e-mail service.)

The invitation lead to a recruitment site  - The Switch Network  - which asked about my willingness to participate in a range of political actions -- from signing a petition, e-mailing elected officials, attending rallies or demonstrations or testifying at hearings.

A democracy depends on an active and engaged citizenry. But mobilizing addicts during an election?  I think that may be a new one, even for the nicotine industry.

Wednesday, 4 September 2019

Why so anodyne? Canadians need strong, effective and truthful warnings on vaping packages

The federal government summer season of no-big-decisions usually runs from third week of June (St. Jean Baptiste Day) to the first week of September (Labour Day). On the eve of the break this year, Health Canada handed public health groups with a challenging summer task: published in the Canada Gazette on Saturday June 22 were 27 pages of proposed regulations for vaping products. Responses were due 75 days later, on September 5.

The proposed regulations are no trivial matter. They are the first significant regulatory proposals from government to constrain the way that nicotine products are packaged and labelled, or to control the amount or type of nicotine that can be sold as a recreational drug. 

For decades, nicotine other than tobacco was controlled as a medication under the Food and Drugs Act. The tolerance that was given to vape shops was so extensive that many Canadians who bought nicotine liquids for vaping devices were likely unaware that they were participating in an illegal sale.

All this changed when the federal Tobacco and Vaping Products Act was approved by Parliament and proclaimed in May 2018. The legalization of nicotine changed the commercial market, bringing nicotine into the Fast Moving Consumer Goods (FMCG) market. Convenience stores became the route to market for multinational tobacco companies to compete for this new market. (Picture below courtesy of Toronto area South Bayview Bulletin Board).

Health Canada has yet to make public whether or how it will regulate the types of ads that appear in many convenience stores (several provinces have banned them). Their first priority was to develop labelling requirements and child-resistant container requirements. As Health Canada describes them, 

The proposed labelling requirements include a list of ingredients, and, depending on the presence of nicotine and its concentration, a health warning that nicotine is highly addictive, the concentration of nicotine, and warnings regarding the toxicity of nicotine when ingested. In addition, the proposed Regulations would set out expressions that may be used on the product or package to indicate when a vaping product is without nicotine. The proposed Regulations would also require refillable vaping products, including devices and their parts, to be child resistant.

Why so anodyne?

Health Canada's proposals for package warnings for vaping products are surprisingly unambitious for a country which invented graphic health warnings. The regulations require a only a text warning, only for one health effect and only on one side of the package. They are arguably less powerful than the warnings currently placed on a voluntary basis by the industry. 

Canada can do better 

This proposed warning seems even more  milquetoast now than it did when it was first Gazetted in June. South of the border, health authorities have spent the summer snarling at nicotine companies and expressing concerns about potential acute risks for young people who vape:
* top medical authorities issued unequivocal warnings that vaping products are "not safe" for non-smokers, 

Admittedly, only one other country currently requires graphic health warning messages on vaping product packages (South Korea). Admittedly, it is important to design them thoughtfully -- and that takes more than the 75 days given to respond to the proposed regulations. Admittedly, Health Canada should not leave the packages of these risky products unregulated for any longer than necessary.   

For that reason, we are proposing that in the short run, Health Canada require a strengthened and more prominent version of its warning be on all packages as soon as possible. Within the next year, however, it should be possible to refine and adapt a series of rotating messages which provide Canadians with the information about the range of health risks associated with vaping to which they are entitled. One of our suggestions on how to do this is shown below.

How much is too much? How fast is too fast? 

The proposed regulation also sets limits on how much nicotine is permitted in the liquids or cartridges used with vaping devices. The level -- at 66 mg / mL -- is much higher than any of the major products currently on the market. This is in stark contrast to the European Union, Israel, Korea, and Iceland where the maximum level allowed is 20 mg/mL. 

Nor does the regulation address the additional risks of nicotine salts -- which are shown even by the industry research to reach the brain more quickly than those which do not use this 'protonated' technology. It does little to respond to increasing concerns about the collateral damage of the nicotine arms race that is happening between JUUL and its imitators.

A time for sober second thought

More often than not, the final version of regulations varies little from the version that is initially published. Concerns about departmental regulation making once resulted in Parliament being given an opportunity to vet Tobacco regulations before they came into effect. This provision was removed when the law was updated  to include vaping products last year.

So the only recourse left is for a change of opinion by the department and the central agencies (Treasury Board, Privy Council Office, Cabinet) to which it reports. Cross your fingers!

Our submission

Physicians for a Smoke-Free Canada's full response to the proposed regulation can be downloaded here. Our key recommendations are:

1. Vaping packages should carry warnings of the following risks:
  • Vaping products may increase the risk of cardiovascular diseases.
  • Vaping products may increase the risk of lung diseases.
  • Vaping products are not effective smoking cessation devices for most people.
  • Dual use of vaping products and combustible cigarettes increases the risk of disease compared to exclusive use of either product.
  • Use of vaping products during pregnancy may harm the fetus
  • Young people who vape can harm the parts of their brain that control attention, learning, mood and impulse control.
  • Nicotine can harm adolescent brain development, which continues into the early to mid-20s
2. Manufacturers should be required to place warnings on at least 50% of the top of two principal display surfaces, with one side each for English and French.
3. Graphic health warnings for vaping product packages should be developed. 
4. Plain packaging of vaping products should be required.
5. The maximum allowable nicotine concentration should be set at 20 mg/mL.
6. The impact of the introduction of nicotine salts on youth vaping should be reviewed.

Sunday, 1 September 2019

ICYMI: Health Canada releases a trove of research reports on vaping and smoking

Finished with trashy beach novels? Looking for something more gritty to read? Canada's National Library has just the antidote to those light reading blues -- a stack of consumer research reports on Canadians' knowledge, attitudes and behaviours related to tobacco/nicotine.

It's only a little more than a year since the Canadian government opened the door for tobacco company marketing of vaping products (prior to that it was a tolerated grey market supplied by tolerated illegal manufacturers and distributors).

In that time, it has proven frustratingly difficult to assess the impact of this market liberalization on the use of these products. Most of the available survey data on vaping predates the marketing of Juul, Vype, Stlth and other mass marketed nicotine products.

Canada's traditional health surveillance system has a lot going for it -- but it has not yet caught up with the vaping phenomenon. The core federal health surveys (like the Canadian Community Health Survey) have largely ignored e-cigarettes and the specialized surveys (like the Canadian Tobacco Alcohol and Drug Survey) were inexplicably suspended for the year the nicotine market was liberalized.

To address this gap, Health Canada has put significant resources into consumer research. This may not yield the robust indicators on smoking and vaping patterns, but it does helps us understand a little more about what is motivating those who do.

Federal policy dictates that all public opinion research be made public through the library within 6 months of finalizing the field work. Because much of the field work wrapped up at the end of the last fiscal year, the reports were uploaded to the Library of Canada website in late August.

Five of these reports are linked below.

POR 067-18

Qualitative and quantitative research on perceptions of nicotine 

The report covered both smoking and vaping behaviours of Canadians aged 13 years and old, exploring several aspects of each. It involved both focus groups and on-line questionnaires (with more than 4000 respondents online)  and was conducted by the Earnscliffe Strategy Group.  Banner tables from the study are also available, and included with the usual demographic break-downs are information on Indigenous and non-Indigenous populations. (The results showing the much higher use of nicotine and cannabis and much lower expressions of concern by Indigenous participants is sobering indeed!).

Tidbit: 1 in 10 daily smokers also vape with nicotine every day. 4 in 10 vapers smoke every day.

POR 119-18 

Smoking Behaviour Journey Map

This innovative study sought insight into the role that tobacco use played in  adult smokers' lives. More than 500 smokers participated in an on-line survey and of those, 80 smokers submitted daily journals. The study confirmed that "Generally speaking, smoking appears to be a means to manage or cope with feelings and emotions. When it did come up, it was typically associated with the comfort of routine (and primarily the morning routine), or a moment for relaxation or quiet reflection. It can also have a calming effect when feeling overwhelmed or stressed."

Tidbit: 1 in 3 daily smokers use cannabis more than once per week.  1 in 10 use it every day.

POR 093-18 

Smokers and Recent Quitters’ Awareness and Perceptions of Options to Minimize Harms from Nicotine and Tobacco Products

This online survey was taken by 3,500 adult smokers and former smokers.  The researchers originally wanted to question people who had quit in the past year, but were unable to find enough of them. (!)  Given the publicity about e-cigarettes, a surprisingly low number of smokers (30%) acknowledged being familiar with them.

Tidbit: Almost 1 in 10 (8%) of former smokers use e-cigarettes daily. 1 in 6 recent quitters who has tried e-cigarettes continues to use them daily, compared with 1 in 15 recent quitters who has tried the patch and continues to use it.

POR 126-18 

Qualitative Testing of Revised Health Warnings for Cigarette Packages and on Cigarette 

This study reports on focus group testing of proposed health warning messages, and the views of young smokers and non smokers, and young adult and adult smokers. Participants were shown 44 potential health warning messages, and 52 on-cigarette warnings. (No country has yet implemented on-cigarette warnings).

Tidbit: "Reactions to having health warnings printed directly on cigarettes are viscerally negative among participants who smoke, as they are considered unnecessary to warn those who smoke, and a costly approach. However, the presence of on-cigarette health warnings made smoking less attractive to people who smoke and less frequent smokers expressed mixed opinion regarding its potential to impact awareness of health hazards."

POR 058-18

Public Opinion Research on Noticeability of Health Information Messages and effectiveness of Health Warnings for Tobacco Labelling

This online survey of 3000 Canadian smokers (aged 16 years or older) aimed to inform improvements to health information messages and health warning messages.

Tidbit:  1 in 3 smokers cannot recall seeing the Health Information Messages, even though they have been printed within each cigarette package for almost 20 years. 

Wednesday, 21 August 2019

Are we prepared for an e-cigarette price war?

CNBC reported today that the price war among vaping companies in the United States is driving the cost of experimenting with nicotine to below the cost of a candy bar. Some starter kits can be bought for as little as US$0.99. 

"Late last year, NJOY started selling its Ace e-cigarettes for 99 cents in stores, compared with the $7.99 it currently charges online." (Pictured below is one such offer from a US web-retailer).

The price war among vaping companies in Canada as not yet hit that level, although, as reported here earlier this summer, it has resulted in the price of  major vaping devices being cut in half in only 6 months. Thankfully they are not (at least yet!) at the levels observed in the USA.

It  could be only a matter of time before the companies launch a full-scale price war in Canada. If so, there is little sign that governments will be able to prevent young people from becoming collateral damage.

What could they be doing?  I'm glad you asked.

* Health ministries could prepare to amend tobacco and vaping laws in order to give themselves regulatory authority over promotional prices. Many of these laws already have some form of restraint on using price to induce young users -- measures like minimum package sizes and bans on certain discounts. But for the most part, price promotions for tobacco products (including vaping) are currently exempted. Filling this loop hole is more important than ever.

* the federal department of Innovation, Science and Economic Development (formerly Industry Canada) could prepare to undo the damage it imposed in 2009, when it  amended the Competition Act in the infamous omnibus budget bill of 2009. Before then, manufacturers could not set discriminatory wholesale prices between retailers. By re-inserting restrictions on wholesale price discounting for harmful products like tobacco and nicotine, this department could end the localized pricing practices that are undermining tobacco tax policies and stop them from expanding into nicotine.

* finance ministries can be exploring optimum tax policies for e-cigarettes. The World Bank has scoped out the use of taxes to discourage young people from vaping, and several U.S. states and other countries have already put e-cigarette taxes into effect. (Pictured below is the impact that US state-level taxes would have on a package of cartridge in Canada).

The importance of tax and price policies to reduce tobacco use has been recognized for several decades- and is a cornerstone of the Framework Convention on Tobacco Control

How many more children need to be addicted before this tool is taken out of the shed?

Tuesday, 13 August 2019

Monetizing peer pressure: JUUL joins in.

Some months ago, I received an e-mail from the Canadian marketers of Philip Morris' IQOS offering me the opportunity to earn $75 by putting them in touch with one of my friends who was willing to buy one of their products. "Each referred friend who meets an IQOS expert will receive $25", they promised and "For every friend who purchases IQOS, you will receive $75."

This, I believe, was a departure in tobacco marketing in Canada. I could not recall a previous time when tobacco companies recruited such a direct and sales-focused type of 'paid influencer'.

One might have thought that this practice was banned by Canadian tobacco law, which has for many years told manufacturers that they can't offer prizes, money or other inducements to purchase tobacco products. (IQOS and other heat-not-burn devices are considered tobacco products under federal law).

The ban was recently reaffirmed when the federal Tobacco and Vaping Products Act was overhauled in 2018:

29 No manufacturer or retailer shall
(a) provide or offer to provide any consideration, for the purchase of a tobacco product, including a gift to a purchaser or a third party, bonus, premium, cash rebate or right to participate in a game, draw, lottery or contest...

Six months have passed since Physicians for a Smoke-Free Canada filed a complaint to Health Canada about the IQOS referral offer yet the IQOS referral web-site is still active (referiqos.com).

Which brings us to JUUL.

Yesterday, JUUL presented me with a similar, if somewhat less lucrative, offer. As the e-mail presented the offer, every referred adult smoker who makes a purchase gets a discount of $20 on their account, with a similar credit given to the person who referred them.

The federal law sets different rules for vaping promotions than it does for tobacco. You are allowed to offer cash or other 'considerations' -- but only in a physical store ("retail establishment") to which young persons do not have access.

30.6 (1) No manufacturer or retailer shall, in a place to which young persons have access,
(a) offer to provide any consideration, for the purchase of a vaping product, including a gift to a purchaser or a third party, bonus, premium, cash rebate or right to participate in a game, draw, lottery or contest; or
(b) offer to furnish a vaping product in consideration of the purchase of a product or service or the performance of a service.

(2) No manufacturer or retailer shall, in a place other than a retail establishment where vaping products are ordinarily sold,
(a) provide any consideration, for the purchase of a vaping product, including a gift to a purchaser or a third party, bonus, premium, cash rebate or right to participate in a game, draw, lottery or contest; or
(b) furnish a vaping product in consideration of the purchase of a product or service or the performance of a service.

Influence peddling

Tobacco companies have long known that peer pressure is a driving force for uptake of nicotine. Imperial Tobacco Canada (BAT) infamously studied the role that peer pressure played in teenagers - its Project 16 report found "there is no doubt that peer group influence is the single most important factor in the decision by an adolescent to smoke."  

New communications technologies now allow the companies to harness the power of peer pressure -- and the law seems unable to prevent it from happening.

Everything new is old again

For a century, tobacco companies have pioneered marketing strategies and pushed the envelope of marketing codes and legal restrictions. For decades, governments have been caught flat footed, unable to keep up with, let alone control, the inventiveness and deep pockets of marketers. The difference now is that we know the consequences of regulatory inaction.

If paying people to encourage their friends to use use of addictive and harmful products is permitted under the federal TVPA, then a new law is needed.

Thursday, 8 August 2019

Imperial Tobacco is encouraging you to pimp your vape

On July, Imperial Tobacco posted an ad on its Instagram account, announcing that "ePod Skin Collections are coming soon. Stay tuned! Happy Canada Day!" 

Sure enough, later last month the company put on offer 19 different sleeves that can be used to dress up a vaping device. They are pretty spiff, and are sold under evocative descriptors like "maze", "tropico", "relief", and "express". The skins can be ordered from the company'  web-site for about $4 each.

When decorative covers were first sold by British American Tobacco for the ePen 3 in the United Kingdom, they were launched as "high fashion pieces" commissioned by clothing designer Henry Holland. His aim was to help consumers incorporate things in their lives that gave them "positivity", "empowerment" and helped them "feel really good about themselves."

Res ipsa loquitur

Linking addictive nicotine to a fashion lifestyle is likely not permitted under Canada's federal Tobacco and Vaping Products Act (s. 30.2), which may be why there was no similarly splashy launch to sale of these fashion accessories in Canada.

The Tobacco and Vaping Products Act says that "30.2 No person shall promote a vaping product, a vaping product-related brand element or a thing that displays a vaping product-related brand element by means of lifestyle advertising."

Health Canada recently finalized regulations to put cigarettes in plain packaging. One of the reasons for doing so was that branded packages functioned as 'mini-billboards', encouraging young people to try smoking.

By the same logic, these fancy-dress sleeves will serve as mini-billboards for vaping products -- a consumer-carried lifestyle advertisements.

Only in Canada, you say?  Pity.

The skins are not yet listed for sale in the few other countries where the epod is marketed, eg FranceGermany and the United Kingdom.

Visualizing the gains since 2000

I spent my coffee break this morning playing with the *awesome* visualization tools made available courtesy of ourworldindata.org based on data provided by the World Health Organization.

Enormous strides have been made over the past decade in standardizing health indicators and in making data available for analysis in ways previously unimaginable. Our thanks to those who have invested in this important work.

For reasons never made clear, Canadian health authorities have rarely age-standardized smoking rates. Most people start smoking when they are young and a proportion of them quit as they age - so it doesn't make sense to compare the smoking rates of a relatively young population (say Africa or Canada in the 1960s) with those of a relatively old population (say Japan or Canada in 2017!).

Because WHO age standardizes smoking rates in its Global Health Observatory repository, we can compare Canada's progress with other countries with a little more confidence.

The charts below suggest that:
  • wealthy countries with modest anti-smoking programs (France and Germany) have made little progress in reducing current smoking (daily and occasional) among men or women
  • wealthy countries with more active anti-smoking strategies and liberalized markets for harm-reduction/tobacco alternatives (United Kingdom, United States, Sweden), have made more progress against smoking
  • wealthy countries with more active smoking strategies and restricted markets for harm-reduction/tobacco alternatives (Canada  until 2016, Australia) have made similar progress. 
  • developing countries with more active smoking strategies and restricted markets for tobacco alternatives (Thailand, Brazil) have similarly made progress.

Data is more plentiful, more accurate and more usable -- but it still isn't enough to make a prima facie case that liberalized nicotine markets drive down current smoking. More analysis needed!