Tuesday 30 August 2022

BAT's VUSE in Canada: more flavours and new nicotine strength bands

Screenshot of 45 flavours of
nicotine capsules
sold by BAT in Canada
(August 2022)
Earlier this spring, we reported on hardware and cosmetic changes to the VUSE vaping device sold by British American Tobacco/Imperial Tobacco Canada Ltd (BAT-ITL) was marketing its VUSE brand ePOD vaping device. Among these developments were the ability of consumers (and the company?) to monitor device use and location through internet connections, increased personalization of nicotine delivery and cosmetic elements and the expansion of flagship stores.

This post reports on the further evolution of the company's marketing activities: its continuously expanding flavour range and its introduction of strength bands for nicotine, similar to those in place for its cigarettes.


BAT-ITL currently only sells the cartridge-based ePOD line of vaping devices in Canada. The ePOD device was introduced to Canada at the beginning of 2019 with 5 flavour offerings. In January 2020, the number of flavours offered had grown to 8, increasing to 22 flavours in January 2021 and 30 flavours in January 2022. This month (August 2022) there are more than 40 flavours available for nicotine liquids.

The ePod capsules were originally sold in Canada in 3 nicotine strengths (1.6%, 3% and 5%), but for a year after Health Canada imposed a ceiling on nicotine concentrations in 2021 only one strength (18 mg/ml, 1.6%) was available, in addition to nicotine-free. Today, as discussed below, three nicotine levels are available.

BAT does not sell the same vaping products in all markets, reflecting both regulatory and market differences, as seen in their offerings in its 5 largest vaping markets :  Canada, France, Germany, the UK and the  USA. 

BAT sells fewer devices in Canada. In the United Kingdom and France it also sells the eTank and ePen, and has recently introduced the disposable VUSE GO/PUFF. In the United States, BAT's subsidiary sells the ePOD under the name ALTO as well as three cigalike products (SOLO, CIRO and VIBE).

BAT sells more flavours in Canada. In France, ePod cartridges are sold in 19 flavours, in the United Kingdom, 20 flavours are available and in Germany there are 7 ePOD flavours sold. In the USA, the only flavours sold are tobacco-flavours (of which there are two) and menthol, which is in line with FDA signals that other flavours will not be permitted.

BAT sells higher nicotine in Canada than in Europe. In France and the UK, nicotine concentration is capped at 20 mg/ml as it is in Canada. In those countries, however, BAT offers some much lower nicotine strengths than it does in Canada (e.g. 3 mg/ml and  6 mg/ml) as well as offering 12 mg/ml and 18 mg/ml as it does in Canada and Germany. There is no maximum nicotine concentration in the USA, and the range of nicotine concentrations for ePOD-ALTO capsules include higher but not lower strengths than are sold in Canada (e.g. 18, 24 and 50 mg/ml).

The continuous expansion of flavours

This spring, BAT-ITL passed the '31 Flavour' threshold in Canada, now selling more flavours than leading ice-cream chains. As noted above, the number of flavours has doubled over the past 18 months, and sextupled since the year before. 

Most of the new flavours introduced this summer are in the flavour categories that Health Canada has indicated would be exempted from any flavouring restrictions:  tobacco-flavour and mint-menthol. They are also the flavours that are subject to fewer provincial flavour restrictions

Since May 2022, the number of mint-menthol flavours for ePOD capsules has grown from 6 to 13, and the number of tobacco flavours has grown from 7 to 13.

6 mint-flavoured ePOD liquids listed in May 2022: 

13 mint-flavoured ePOD liquids listed in August 2022:

This marketing strategy creates several concerns for public health authorities: 

Promoting flavours helps BAT introduce "new entrants" to nicotine. BAT has reported that the majority of people who use their vaping products are "new entrants", [1] by which they mean they are people who have not previously smoked or used other nicotine products. For these non-smokers, flavours do more than encourage trial, they also mask the bitterness of nicotine.

Continued taste tests help BAT turn experimenters into nicotine addicts. Researchers (including in Canada [2]) have established the brief trajectory from a first cigarette puff to medically-defined dependence. If, as we should expect, the milestones to addiction are similar for vaping products, BAT knows that it needs to encourage users to move beyond a first experimental puff to subsequent experiments and regular use. The strategy based on continued experimentation needs a continuous supply of "new" flavours. 

The focus on flavours interferes with awareness of risks. Directing attention to flavour 'notes' and 'intensity' serves to increase the importance of flavours to the user, and reinforce the pleasurable aspects of the vaping experience. This serves to downplay the inherent health risks of the product.

Flavourings increase the risks of vaping. In addition to their role in attracting new users and establishing addiction, flavourings also make vaping more dangerous by increasing the exposure of users to harmful chemicals and particulates. 

BAT's flavour promotions include the development of a lexicon to discuss flavour experiences. In addition to the the flavour card shown here, the company offers an interactive VUSE IQ on line and in its stores to guide flavour selections.

Nicotine strength bands that echo cigarette marketing

This summer, the company began marketing their e-liquids in Canada in three bands of nicotine strength, in addition to nicotine-free. The salted 1.6% formulation is now labelled "balanced", against which "mellow" and "bold" strength versions are compared.

* BOLD liquids (also sold as V-ULTRA) are made with slightly more nicotine (20 mg/ml instead of 18 mg/ml), and use free-base nicotine which has a stronger throat impact and is less easy to inhale [3]. BAT uses blog posts, social media and direct mail to promote this as "a bold nicotine experience and an intense sensorial kick."

* MELLOW liquids have one-third less salted nicotine than balanced (12 mg/ml or 1.1%). Web promotions, social media and direct mail promote this as "a Mel-low nicotine experience" - "high on flavour, low on nicotine".

This strategy echoes the presentation of BAT cigarettes, such as John Player, as 'mellow', 'smooth', 'rich' and 'bold'. Although the company maintains these descriptors relate to taste, and not nicotine strength, they originate in the era when 'light'/'mellow' cigarettes were promoted as being less harmful or addictive.

Coming soon to Canada? BAT's VUSE disposables:

This summer BAT told investors that the sale of its disposable vape, Vuse GO "will be scaled-up and rolled out into a number of new markets."  [4] 

The launch date in Canada has not yet been made public, although the way has been paved with the registration of several trademarks. (2172906, 2172945, 2181154, 2181167, 2174079, 2172918

Canada's second-largest tobacco company launched its disposable VEEBA earlier this summer: BAT's introduction may not be too far away. 

Implications for regulators

BAT's marketing strategy may be flying below the public health radar. 

This year BAT has launched new vaping retail outlets, has started connecting vaping devices to monitoring systems, has added jewelry and other cosmetic features to its vaping devices and has greatly expanded the range of flavours and marketing techniques to promote them. Each of these measures appears designed to increase the use of vaping products for pleasure (not cessation). 

None of their actions this year has elicited a response from any of Canada's 14 health regulators. No government has disclosed any system in place to monitor these market changes.  (The regulations proposed by Health Canada this summer do not include any requirements to report on promotional activities.)  Unlike most other countries, there are no requirements for BAT to notify Canadian health authorities before selling vaping liquids and devices, allowing it to use Canada as a proving ground for its global brands.

Proposals to restrict flavourings, currently under review in Canada and elsewhere,  are largely based on research that treats "tobacco flavour" and "menthol flavour" as two flavourings and not two flavour ranges encompassing dozens of flavours. BAT's launch of 26 flavours in these two categories suggests that it is poised to blunt the impact of federal restrictions originally considered to restrict the number of flavourings.

[1] BAT Capital Markets Day 2019. Step-Changing New Categories. A very significant growth opportunity. https://www.bat.com/group/sites/UK__9ZTFCM.nsf/vwPagesWebLive/DOBA7JRL/$FILE/Step-Changing_New_Categories_-_A_very_significant_growth_opportunity.pdf?openelement

[2] André Gervais, Jennifer O’Loughlin, Garbis Meshefedjian, Christina Bancej, Michèle Tremblay
Milestones in the natural course of onset of cigarette use among adolescents. CMAJ • August 1, 2006

[3] SohaTalih, Rola Salman, Rachel El‑Hage, Nareg Karaoghlanian, Ahmad El‑Hellani, Najat Saliba and Alan Shihadeh. Effect of free‑base and protonated nicotine on nicotine yield from electronic cigarettes with varying power and liquid vehicle. Nature. (2020) 10:16263

[4] BAT. News Release. Half-Year Report to 30 June 2022.  27 July 2022. https://www.bat.com/group/sites/UK__9D9KCY.nsf/vwPagesWebLive/DOCGKBGW

Friday 12 August 2022

Update on e-liquid flavour restrictions

Almost 14 months have passed since Health Canada published draft regulations to restrict the flavourings and chemicals that could be used by e-liquid manufacturers. in vaping liquids. This post reports on developments in Canada and elsewhere that are related to restricting e-cigarette flavours. Links to more information are provided at the end of the post.

Lots of noise from the vaping industry

The proposal to limit e-cigarette manufacturers to two flavour categories (tobacco and mint/menthol) was met with significant opposition, much of it managed through campaigns funded by the nicotine industry

These campaigns have included street level demonstrations in several Canadian cities, write-in campaigns, and dozens of meetings with elected officials. (Image below shows officially registered lobbying activities since October 2021).

House of Commons Seating Plan
(check mark indicates registered communication on vaping issues since October 2021) 

But mostly silence from Canada's federal government. 

It is difficult to speak with confidence about the future of these regulations, or the likelihood that they will become law in Canada in the near future.

Interpreting the pause in moving them forward is made more difficult by the many factors that may be influencing the process. These include the disruption to the decision-making process that naturally flowed from the federal election held in late September 2021. Although it returned the same party to power, the election nonetheless served to reboot the government process, interrupting progress on many files. It also triggered changes to some of the key decision-makers: a new minister was assigned to tobacco and vaping issues, which also let to a new team of political advisors on the file. 

The election and its aftermath resulted in an evolution of government priorities. Those for the new Parliament were outlined in general terms in a Throne Speech and in more specific detail in the new mandate letters issued to cabinet ministers. Neither of these made any reference to vaping regulations. Nor was there a firm commitment to complete the regulation in the nuanced response of the government party to the election questionnaire circulated by the Heart and Stroke Foundation.

At a political level, the past year has been marked by silence on the topic. No ministerial Tweets. No speeches. No Parliamentary questions, answers or statements.The sole official mention to date is in the background information to a June 2022 news release, which noted that the department is still "reviewing feedback" on the flavour restriction proposal. 

At the departmental level, planning documents suggest some wiggle-room was sought on this file. This year's Departmental Plan, noted that there would be "ongoing work" on the regulations, but did not use the term "finalizing" as it did for some other regulations. Intention to regulate was also identified in the Forward Regulatory Plan published by the department in February but unlike other regulatory proposals, this one included no timeframe for the next step.

Forward movement in some jurisdictions ...

In the year that Ottawa has been  'reviewing feedback', other jurisdictions have moved forward to ban the sale of flavoured e-liquids.

Two more Canadian jurisdictions implement flavour bans

One more province and one more territory have implemented bans on e-liquid flavourings other than tobacco. New Brunswick's restrictions came into force on September 1, 2021 and the Northwest Territories on March 25, 2022. Together with the three other jurisdictions which have adopted this measure (Nova Scotia, April 2020; Prince Edward Island, March 1, 2021, Nunavut, TBD), 5 of 13 provincial or territorial governments  have adopted this policy. 

Two more European countries implement flavour bans

A year ago, only 3 European countries had banned flavourings: two banning all but tobacco (Finland, 2016; Hungary 2020), and one also permitting menthol (Estonia, 2019). Today, flavourings are prohibited in two more countries: on April 1, Denmark implemented its ban on all flavours other than tobacco and menthol and Lithuania's ban on all flavours but tobacco came into force on July 1, 2022.

Two additional European countries have set implementation dates for regulations: the Netherlands proposes to ban flavours as of January 2023, and last December the Ukraine passed a law to implement a flavour ban in July 2023. 

The world's two largest vaping markets clamp down on flavours

A year ago there was little indication that China was intending to clamp down on the e-cigarette market. In a sweeping set of reforms, that country has now imposed controls on this market which include a prohibition on all flavours other than tobacco flavour. These measures will come into force on October 1. 

The United States Food and Drug Authority became responsible for regulating e-cigarettes in 2016, and was required by U.S. law to determine whether the marketing of each individual product was 'appropriate for the protection of public health'. Last August, the FDA began to exert this authority, ordering 55,000 products removed from store shelves. To date, more than 250 manufacturers have been issued marketing denial orders (The FDA's list can be downloaded here). Some flavoured products remain on the market, however, as legal challenges to the FDA's decisions are being reviewed by courts.

Of those products that have received  marketing authorization from the FDA, the only flavour permitted has been tobacco-flavour. The FDA has deferred decisions on menthol-flavourings, but for products on which decisions have been made, no other flavours have received market authorization. The FDA recently explained its rationale: "For flavored ENDS (i.e., ENDS with e-liquid flavors other than tobacco or menthol, such as fruit), there is a known and substantial risk of youth initiation and use; accordingly, an applicant has a higher burden to establish that the likely benefits to adult smokers outweigh that risk. For tobacco-flavored ENDS the risk to youth is lower; accordingly, a lesser showing of benefit may suffice. Assessments for menthol flavored ENDS will be addressed separately. When it comes to evaluating the risks and benefits of a marketing authorization, the assessment for menthol ENDS, as compared to other flavored ENDS, raises unique considerations."

Two more legislatures call on governments to ban flavours

This June, the Joint Committee on Health of Ireland's Oireachtais recommended that the government's proposed Tobacco and Nicotine Inhaling Products bill should be amended to ban flavours: "The Bill should regulate the flavouring of e-cigarettes and all flavours except for tobacco, should be strictly prohibited so as not to entice minors."

In May, Hawaii's State Legislature passed legislation (HB1570) to ban all e-cigarette flavours. This would have made Hawaii the fifth U.S. state to do so (after New York, New Jersey, Massachusetts and Rhode Island), had not the bill been vetoed by the governor in mid-July.

... Backwards movement in others

Over the past year three legislatures have rejected or overturned proposals from health authorities to limit or ban the use of flavourings in e-cigarettes.

In March, the Swedish government introduced legislation ("Stricter rules for new nicotine products") but the section which would have banned all flavours but tobacco was removed from the law during the review by the committee. The bill passed in June without this section. 

The Icelandic legislative committee similarly removed language from the government's proposal for regulatory authority to ban flavourings and the bill was passed in June without this authority.

The Philippines Congress passed a law which overturned a previous ban on e-cigarette flavourings (and also remove other restrictions on the market, including a prohibition on selling to those under 21). The ban on flavourings in the Philippines was in effect from May, when the former law came into effect, until July, when the new law came into force.

More than half world's citizens live in countries whose health authorities do not approve the sale of flavoured e-cigarettes.

The regulatory decisions by the Chinese government and the administrative actions of the U.S. Food and Drug Authority increases the proportion of the global population which lives in countries where flavoured e-cigarettes are not authorized for sale to over 20%. In addition, approximately 40% of the global population lives in countries where e-cigarettes cannot be sold at all as consumer products.

More health agencies call for flavor bans

In all the jurisdictions where e-cigarettes are permitted for sale and where flavour bans has been formally discussed, major health organizations have taken the position that flavourings should restricted. 

In Canada, those in favour of a ban on flavoured e-liquids include: The Association of Local Public Health Agencies (alPHa)Association of Quebec Cardiologists, Association des chirurgiens-dentistes du QuébecAssociation des intervenants en dépendance du QuébecAssociation des pédiatres du QuébecAssociation des pneumologues de la province de QuébecAssociation pulmonaire du Québecthe Canadian Cancer Society, the Canadian Council of Chief Medical Officers of Health, the Canadian Dental Hygienists Association, the Canadian Lung Association, the Canadian Thoracic Society, the Canadian Medical Association, the Canadian Paediatric Society, Conseil Québécois sur le tabac et la santéDirection de Santé Publique de la Gaspésie et des Îles de la MadeleineHeart and Stroke, the Institut national de santé publique du Québec, Middlesex-London Health UnitNew Brunswick Medical AssociationPhysicians for a Smoke-Free Canada, the Registered Nurses Association of OntarioToronto Public Health

In the United States, virtually all of the major American health organizations have called for a ban on all flavours but tobacco. These include the American Academy of Family Physicians, the American Academy of Pediatrics, the American Cancer Society, the American Heart Association, the American Lung Association, the American Medical Association, Campaign for Tobacco-Free Kids, CHEST (formerly American College of Chest Physicians), Truth Initiative

International health organizations which have called for flavour bans include the Forum of International Respiratory Societies and World Heart Federation, and Cancer Societies and Heart Foundations in several European countries.

Monday 8 August 2022

ICYMI: selected TC research published in July 2022

This post identifies selected articles and books published in July 2022 that should be of interest to the tobacco regulator and which are available to the general public.


In Quit Smoking Weapons of Mass Distraction, emeritus professor of Public Health Simon Chapman draws on his decades of experience as a researcher and advocate in tobacco control to offer advice on where our attention should - and should not - be focused. This free e-book offers his analysis of the way in which promotion of assisted quitting has been a distraction from more powerful options for reducing smoking. 

His Australian colleague, Mike Daube recommends: “This is a splendid read for anyone interested in what really works to reduce smoking, and what helps to keep Big Tobacco in business. In Simon Chapman’s typically trenchant style, it tells you everything you want to know (and some people won’t want to know) about the myths and realities of smoking cessation and other aspects of tobacco policy. All this alongside lessons learned from a lifetime’s work on tobacco. Top class – don’t miss it.”

Quit Smoking Weapons of Mass Distraction
Simon Chapman
Sydney University Press, July 2022


Oxford University Press published "Policy Success in Canada", an open-access collection of 22 case-studies where Canadian governments and communities have successfully addressed public concerns through policy change. The editorial team that collected these studies was led by Dr. Evert Lindquist of the University of Victoria. The chapter on Canada's Long March Against Tobacco traces events over the past 100 years -- from the first failed attempts to legislate tobacco in the early 1900 to the more recent successes and challenges. 

Policy Success in Canada Cases, Lessons, Challenges
Edited by Evert Lindquist, Michael Howlett, Grace Skogstad, Geneviève Tellier, and Paul t' Hart. 
Oxford University Press (July 30 2022)




The article on "Tobacco Addiction" written by Dr. Selby and Dr. Zawertailo and published in the New England Journal of Medicine was profiled in a separate post. This review updates advice to physicians to support quit attempts. Accessing the article is free, but requires registration.

Selby, P and Zawertailo, L. Tobacco Addiction
N Engl J Med 2022; 387:345-354


The real-life experience of 1,045 English smokers who attempted to quit smoking between 2015 and 2020 was reviewed by a research team lead by Sarah Jackson and the results were published in Real-world effectiveness of smoking cessation aids: A population survey in England with 12-month follow-up. The self-reported success of those who used quitting aids was assessed against that of the 40% who quit on their own. Those who reported using varenicline were more than twice as likely to have quit, but there was no difference for those who used e-cigarettes, prescription NRT, over-the-counter NRT or traditional behavioural support.

Jackson SE, Kock L, Kotz D, Brown J. Real-world effectiveness of smoking cessation aids: A population survey in England with 12-month follow-up, 2015-2020. Addict Behav. 2022 Jul 25;135:107442. doi: 10.1016/j.addbeh.2022.107442. 


Smoking and vaping behaviours

Tobacco and cannabis.  Among the many articles published this summer by the ITC consortium was one which suggests that 3 in 10 Canadian daily smokers are regular users of cannabis. Shanon Gravely is lead author on the study which found that smokers who use cannabis more than once a week are also "more likely to be younger, have lower income, be experiencing financial stress ...have depressive symptoms, use alcohol more frequently and binge drink, use other tobacco/nicotine products, and perceive smoking cannabis as low health risk and less harmful than smoking cigarettes."

Gravely S, Driezen P, McClure EA, Hammond D, Michael Cummings K, Chan G, Hyland A, Borland R, East KA, Fong GT, Schauer GL, Quah ACK, Ouimet J, Smith DM. Differences between adults who smoke cigarettes daily and do and do not co-use cannabis: Findings from the 2020 ITC four country smoking and vaping survey. Addict Behav. 2022 Jul 21;135:107434. doi: 10.1016/j.addbeh.2022.107434. 

Gravely et al. 


Tobacco and vaping among adolescents. Data from the longitudinal COMPASS survey were used to explore whether the involvement of public health agencies in school-based programming was associated with differences in substance use in those schools. Trish Burnett was the lead author on this report which found that overall there was no difference in smoking and vaping among schools where local health units were involved and those where they weren't, but that some differences were seen in schools with higher or lower rates of use.  

Burnett T, Battista K, Butt M, Sherifali D, Leatherdale ST, Dobbins M. The association between public health engagement in school-based substance use prevention programs and student alcohol, cannabis, e-cigarette and cigarette use. Can J Public Health. 2022 Jul 21:1–10. doi: 10.17269/s41997-022-00655-3. 


Vaping among adolescents.
Analysts working at Statistics Canada compiled data from three surveys to identify the circumstances associated with higher rates of e-cigarette use. Michelle Rotermann and her colleague identified social (having friends who vaped), behavioural (having used alcohol, cannabis or tobacco and having worked, school performance), family (having parents who did not know where they were) and demographic (being male and Canadian-born) factors were associated with higher rates of vaping. The study also found that among teenagers who both smoked and vaped, e-cigarettes came first for two-thirds.

Rotermann M, Gilmour H. Correlates of vaping among adolescents in Canada. Health Rep. 2022 Jul 20;33(7):24-35. doi: 10.25318/82-003-x202200700003-eng. PMID: 35862070.


Health effects of tobacco use or vaping 

Health effects of tobacco. The Global Burden of Disease project published a review of the burden of chronic obstructive pulmonary disease (COPD), noting that nearly half of smokers world-wide develop COPD. Of the 3.3 million deaths from COPD world-wide in 2019, there were 8,312 in Canada. The data linked to this paper shows that while deaths from tobacco-caused cardiovascular disease have fallen in Canada since 1990, this has not been the case for COPD or cancers.  (Data is available for non-commercial use upon registration)

Safiri S, Carson-Chahhoud K, Noori M, Nejadghaderi SA, Sullman MJM, Ahmadian Heris J, Ansarin K, Mansournia MA, Collins GS, Kolahi AA, Kaufman JS. Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019. BMJ. 2022 Jul 27;378:e069679. doi: 10.1136/bmj-2021-069679. PMID: 35896191.

IMHE: Global Burden of Disease Study data


Health effects of e-cigarettes. Another review of the health effects of e-cigarettes was published, this one focusing on the differing methodologies used by researchers working in this area. With lead author Nargiz Travis, this research team found that many of the studies did not satisfy AMSTAR-2 criteria. Nonetheless, the report  found "that short-term use of e-cigarettes may be associated with acute cardiopulmonary risks, although to a lesser extent than cigarette use. Long-term e-cigarette use may have pulmonary/respiratory benefits in those who switch from chronic cigarette smoking, particularly in individuals with asthma and chronic obstructive pulmonary disease (COPD). Evidence on intermediate and long-term carcinogenic effects is lacking." The authors recommended more consistency of reporting and more research on newer devices.

Travis N, Knoll M, Cadham CJ, Cook S, Warner KE, Fleischer NL, Douglas CE, Sánchez-Romero LM, Mistry R, Meza R, Hirschtick JL, Levy DT. Health Effects of Electronic Cigarettes: An Umbrella Review and Methodological Considerations. Int J Environ Res Public Health. 2022 Jul 25;19(15):9054. doi: 10.3390/ijerph19159054. PMID: 35897421; PMCID: PMC9330875.

Travis et al, 2022


Tuesday 2 August 2022

Updated advice to physicians on how to treat tobacco addiction.

For decades now, smokers have been encouraged to "ask their doctors" for help in quitting smoking. And for almost as long, doctors have been encouraged to "ask, advise, assist" their patients who smoke to take steps towards quitting.

But what advice should doctors give? And has that advice changed in response to the marketing of e-cigarettes?

This post reports on the evolving advice given to Canadian physicians.

Can-Adaptt and beyond ... 

A decade ago, Health Canada funded the development of guidelines through CAN-ADAPTT. These guidelines, published in 2012, were coordinated through the Center for Addictions and Mental Health, and lead by Dr. Peter Selby, and remain available in a variety of user-friendly forms, and provide advice for specific populations.

A decade on, a review and update of these guidelines would be expected. One of the groups that is working on an update is the Canadian Task Force on Preventive Health Care (formerly known as the Canadian Task Force on Periodic Health Examination). This body was created by the federal government and currently operates with the support of the Public Health Agency of Canada. `

For the past 5 years, this task force has been reviewing guidelines for treating Tobacco Smoking in Adults, and 4 years have passed since it  published the protocol for its evidence review. It was anticipated that this review would be done in two stages: the first on existing stop smoking interventions, and the "second stage will involve updating a systematic review on electronic cigarettes." The finalization of this review has been delayed, and is now slated for "2022/2023"

Meanwhile, Dr. Selby and his CAMH colleague Dr. Zawertailo produced an independent review of the evidence and update of advice to practitioners. 

Last week their results were published in an article "Tobacco Addiction" published last week in the New England Journal of Medicine (access is free, but requires registration). Their review focuses on the effectiveness of well-known therapies (counselling, nicotine replacement, verenicline and burpoprion), while also touching on "second-line" agents like nortriptyline, clonidine or more recently-tested drugs like psilocybin.

The evolution of advice on the effectiveness of vaping to quit.  

This is the first scientific reviews by a leading Canadian expert in smoking cessation since e-cigarettes have been legalized for sale in Canada. 

It is the first published Canadian review since 2018, when Health Canada began to gently encourage smokers to see e-cigarettes as "linked to improved rates of success" in quitting. (Concerns were raised about this advice in the departmental evaluation of the program, and there are plans to update the web-site by the end of this month). 

Practitioners and smokers in Canada continue to get equivocal advice on whether or not e-cigarettes are helpful in quitting. CAMH, for example, counsels that "using e-cigarettes is NOT a proven strategy to help you quit smoking." On the other hand, the Lower-Risk Nicotine Use Guidelines (which were developed with CAMH) recommend that "E-cigarettes with nicotine may be an effective cessation aid for people who use combustible tobacco."

In the NEJM review, Drs. Selby and Zawertailo were unequivocal in their conclusions on this point: "We would recommend against the use of e-cigarettes for smoking cessation given insufficient evidence to support their use." Instead, they recommend that physicians support their patients' quitting attempts by using prescription medications as a first-line treatment, either alone or in combination with  NRT. They recommend that these quit attempts also be supported by counselling and follow-up. 

These conclusions are in line with those published last year by the US Preventive Services Task Force, and the previous year by the U.S. Surgeon General (2020),

Changing products force greater uncertainty

Drs. Selby and Zawertailo identify the "areas of uncertainty" that have cast doubt on previous research findings on e-cigarettes. While there has been "moderate-certainty evidence that nicotine e-cigarettes are more effective than nicotine-replacement therapy" .. the  "trials [which] have involved e-cigarettes that are no longer on the market, and study of newer e-cigarette types (e.g., nicotine salt-pod devices) is warranted."

The same issues were discussed in greater length during a  review conducted for the Australian government and published this spring. This review explained why the results of a few clinical trials with older products do not provide relevant evidence for the use of much-changed devices and liquids.

  • There is limited evidence that, in the clinical context, freebase nicotine e-cigarettes may be more efficacious for smoking cessation than existing NRT, and that nicotine e-cigarettes may be more efficacious than no intervention or usual care. 
  • Trials demonstrating efficacy were limited to products with freebase nicotine concentrations ≤20mg/mL. There is no evidence that nicotine salt products are efficacious for smoking cessation. 
  • There is insufficient evidence that freebase nicotine e-cigarettes are efficacious for smoking cessation, compared to non-nicotine e-cigarettes or that non-nicotine e-cigarettes are efficacious for smoking cessation compared to counselling or approved NRT. 
  • There is insufficient evidence that freebase nicotine e-cigarettes are efficacious outside the clinical setting. 
  • No evidence on nicotine salt products was located and their efficacy for smoking cessation is unknown. 
  • There is limited evidence that use of nicotine e-cigarettes for smoking cessation results in greater ongoing exposure to nicotine than approved NRT, through ongoing exclusive e-cigarette use or dual use if smoking continues