Insights from the recent Canadian Tobacco and Nicotine Survey

Three months ago, Statistics Canada released some results from the Canadian Tobacco and Nicotine Survey (CTNS) This is a one-time survey conducted between the end of October and mid-December in 2019. The survey was taken by 8,600 Canadians, fewer than half of those who were asked to do so (a reponse rate of 44%).

Statistics Canada developed the survey with Health Canada, setting the survey goals to "fill important data gaps related to vaping, cannabis, and tobacco usage" and to "inform policy and provide a current snapshot of use across Canada."

The first results of the CNTS were released by Statistics Canada on March 5. These focused on:

* who was vaping (15% of youth and young adults, but less than 3% of adults);
* what they were vaping (nine times out of ten it was nicotine);
* why they were vaping (kids for fun, adults as a way to quit cigarettes); and
* what they thought about the harms of vaping (opinions varied).

Because this survey is not formally connected to other surveillance tools, drawing comparisons with previously estimated rates of smoking or vaping are problematic.  Nonetheless, as we wrote in March, it seems clear that the expansion of vaping marketing has had a more profound impact on youth and young adults than it has had on adult smokers. The number of young vapers has increased greatly, while the use of vaping products by adult smokers seems to have not changed measurably.

In late May, Statistics Canada generously provided us with the Public Use Microfile for this survey, allowing us to extract information on some key aspects of vaping behaviour among Canadians in 2019.

1.  One-fifth of Canadian vapers are teenagers who have never smoked a whole cigarette.

The survey results show that the number of Canadians who have never smoked cigarettes but who have used e-cigarettes in the past month exceed those who have once smoked but are now vaping instead. This is particularly true for teenagers, where three-quarters of vapers have never smoked a cigarette.

Last fall there were about 1.46 million Canadians who had vaped in the past month. Of these, one-quarter (364,800) were "former smokers." The remainder, in roughly equal quantity, were "never smokers"(535,900) or "current smokers" (559,700 dual users).

Past month vapers by age and smoking status
Statistics Canada.
Canadian Tobacco and Nicotine Survey, 2019

2. For every 100 people who tried vaping, 13 became daily users.
 

A great accomplishment for tobacco control has been establishing an environment where young people do not try smoking cigarettes -- even once. CTNS data reflects that progress: Four-fifths of young people (15 to 24 years of age) reply "no" to the question "Have you ever smoked a whole cigarette," compared with fewer than one-half of those in previous generations (over 25 years of age).

But among those who have ever smoked a cigarette, the proportion who became daily (likely addicted) smokers is the same at every age . Almost one in five (18%) of those who ever smoked a whole cigarette were smoking daily, regardless of their age group. This speaks to the addictive power of cigarettes and nicotine.

For vaping, more than one in eight (13%) of those who ever tried vaping were doing it every day last fall. In this case, however, the pattern is reversed in comparison with smoking. In this case, it is the younger generation who had much higher rates of experimentation than older Canadians. Fewer than one-fifth of adults (16%) had ever tried vaping, compared with more than two-fifths of youth and young adults (41%).

For cannabis, the rate of experimentation was essentially the same for all age groups, although young people were more likely to be daily users. Overall, the rate of daily use was about 9%, consistent with other estimates of rates of addiction to cannabis. 

Population prevalence of ever trying product and percentage of those who were daily users
Statistics Canada. 
Canadian Tobacco and Nicotine Survey, 2019

3. Almost half of smokers made a quit attempt over the past year. Few used a recommended cessation aid. 

Smokers and former smokers who said they had quit in the past year were asked how many times they had stopped smoking for at least one day as part of a quit attempt, and were also asked whether they had used any specific quit methods.

Almost one half (45%) identified making at least one quit attempt, with almost one-third (31%) trying more than twice.

When asked whether they had tried to quit using specific approaches, the majority (70%) said they had tried to quit on their own, and half (54%) said they had tried reducing the number of cigarettes. One-third (35%) said they had switched to vaping, one-quarter (25%) said they had used nicotine replacement and one-fifth (20%) said they had used an "other" method. (Because prescription medication was not identified on the questionnaire, treatments like varenicline may be included under "other"). So few people reported using Quitlines or internet programs that the number is unreportable.

The vast majority (88%) of these quit attempts were unsuccessful. Of the 1.75 million Canadians who tried to quit, only 201,000 were still not smoking at the time of the survey (12%). Differences in the outcomes for those using different cessation approaches were not tested for statistical significance, but are presented below. The largest number of successful quitters were those who identified as using no quit method.

The CTNS also asked current vapers whether they had tried quitting vaping, but is designed only to show how many tried but failed to quit. One-in-three vapers (35%) had tried at least once in the past year, but were still vaping at the time of the survey. This included 30% of those who vaped on a daily basis. 

Methods used by those who tried to quit smoking in past year
Statistics Canada. Canadian Tobacco and Nicotine Survey, 2019

4. Tobacco-flavour is the only vaping flavour not attracting young people to vape.

Those who vaped in the past month were asked what their main reason for vaping was and also which flavours they usually chose. 

Four in ten vapers (39%) give recreational reasons for vaping, saying that the main reason they vape is out of curiosity or because they enjoy it. Tobacco flavours are almost never their usual flavours. The number who made this choice is too small to be reported according to Statistics Canada's guidelines. More than one-half of this group (56%) choose fruit, dessert or candy flavours, and about one-seventh (16%) say they prefer menthol or mint flavours. One-quarter (24%) do not have a usual flavour or have one different than those listed. 

Four in ten vapers (37%) give health-related reasons for vaping, saying the main reason they vape is to quit smoking, to cut down on the number of cigarettes they smoke or to avoid returning to smoking. Among this group, one-quarter (26%) used tobacco flavours. One-fifth (20%) choose mint or menthol flavours and twice as many (41%) choose fruit, desert or candy flavours. 

These differences were not tested for statistical significance, but are presented below. 

Flavour preferences by main reason for vaping
Statistics Canada. 
Canadian Tobacco and Nicotine Survey, 2019

This information is available on a downloadable fact sheet. 

"The JUUL design seems like a play out of the tobacco industry's playbook" - David Kessler, US FDA Commissioner 1990-1997

Dr. Kessler, former Commissioner of the U.S. Food and Drug Administration was talking to the media this week about the problems with the JUUL vaping product. He predicted that JUUL and other similarly designed vaping products are unlikely to be approved by the FDA. (After May 2020, the FDA will be reviewing each e-cigarette design to decide whether there is a public health benefit to allowing it on the market. There is no such review planned for Canada).

JUUL has been much criticized for its appeal to young people. and has been the subject of repeated hearings by the U.S. Congress. As part of those hearings, Dr. Kessler wrote a letter to Congress officials to describe how the very design of JUUL ensnares youth. 

"The unique design of JUUL may facilitate initiation by young people"
In his analysis, Dr. Kessler reached back into tobacco industry files to find that, as early as 1954, the tobacco industry was experimenting with organic acids to produce nicotine salts which had the effect of lowering the pH of cigarettes, thereby reducing harshness, creating a "smooth" smoke and making tobacco smoke easier to inhale.

He explains how JUUL has revived this organic acid technology with the use of benzoic acid, fullfilling a prediction made by the industry in 1985 that “product design changes which make cigarettes more palatable, easier to smoke, or more addictive are also likely to encourage greater uptake of smoking.”

There are no built-in “speed bumps”
Dr. Kessler compared cigarette initiation to a journey with speed bumps.  A cigarette might last for 10 or 15 puffs, then it must be extinguished before lighting another. As a result, it might take a new teenage smoker days or weeks to to consume the 200 or so puffs in his first pack of cigarettes, slowly traversing the "speed bumps" of lighting another and another along the way.

Today, the new teenage smoker is on a superhighway to addiction. There are no speed bumps to slow him or her down. The JUUL pod contains about 200 puffs and a neophyte smoker might consume the whole thing in just a day or two. Becoming addicted to nicotine, a process that for some would take months or years, can now be accomplished in just days  or weeks.

Dr. Kessler also pointed to other design features which facilitate youth uptake:

• an increase in nicotine concentration from 1 or 2.4% to a more addictive 5% was made possible because the organic salts made the experience less harsh. 
• use of flavours like tobacco, mint, fruit and dessert, which mask the off notes and appeal to children with sweetness. (Even though JUUL stopped using some flavours in the USA recently, they have adopted no such policy in Canada.)
• limited visible vapour emission (to avoid detection).

A important design feature not mentioned by Dr. Kessler is the very shape of JUUL.  It is designed to look like a USB key and to be recharged via the USB port on a portable computer.  USB keys and portable computers are friendly to today's wired generation.

JUUL has spawned copycat designs by other manufacturers - similar look, similar flavours, similar high levels of salted nicotine.  Among the imitation brands sold across Canada are Vype, Logic Compact, STLTH, Myle, MyBlu, and others.

The last word goes to Dr. Kessler (and Addison Yeoman):

"The words Addison Yeoman, the general counsel of the tobacco company, Brown & Williamson wrote in 1963 are equally applicable today, 'we are, then in the business of selling nicotine, an addictive drug...'  A long and tragic history has taught us the nicotine addiction begins as a pediatric disease."

Do e-cigarettes beat NRT as cessation aids? A key study provides two opposing results - yet only one was reported.

There are thousands of scientific studies on tobacco use published every month (37,000 so far this year!), but only a few find their way into the mainstream media. Among those, even fewer seem to have real influence on government policies.

In my circles, one of the most influential papers this year was a British study on the effectiveness of e-cigarettes at helping smokers quit. Psychologist Dr. Peter Hajek and his colleagues used the "gold standard" methods of a randomized clinical trial to compare E-cigarettes (consumer products) against NRT (licensed therapies) at as cessation products.

The results of this study were published in the New England Journal of Medicine in January and immediately reported by media outlets across the world. Time magazine said the study showed  "E-Cigs More Effective Than Nicotine Replacements in Helping Smokers Quit", a messages echoed in many Canadian media outlets.

The idea that e-cigs are *twice as good at helping smokers quit* as NRT has now taken root.

Indeed, in some important quarters in Ottawa it seems to have become part of the tobacco control belief system. More than once over the past few months have I have heard this study cited as a reason that governments should continue to allow e-cigarette promotions.

Differing points of view

Yet Dr. Hajek and his team are not the only highly qualified researchers looking into this issue, and theirs is not the only scientific conclusion on offer.

Among other respected public health scientists who have looked at the efficacy of e-cigarettes as cessation products are those at the World Health Organization. This summer, after considering Dr. Hajek's results and others, the WHO concluded:

Although some [Electronic nicotine delivery systems] have been shown to help smokers quit conventional smoking under certain conditions, when used as NRTs the scientific evidence is inconclusive. There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal.

This is not the only time that Dr. Hajek and the World Health Organization have come to starkly different conclusions about interpreting research findings. In 2014, Dr. Hajek was among a research team which openly criticized the WHO, accusing it of "misleading" the public with the following statements:  "Youth are rapidly adopting e-cigarettes", "the hope that e-cigarettes will reduce harm by delivering 'clean' nicotine will not be realized in continuing dual users" and "E-cigarettes deliver lower levels of toxins that conventional cigarettes, but they still deliver some toxins."

Nor is it the first time that Dr. Hajek has nailed his colours to the mast of e-cigarettes being so safe that their use should be promoted. He was part of the scientific team  that advised Public Health England to promote the idea that the differences in harm between e-cigarettes and cigarettes could be quantified, and that the comparative measure was "95% safer". Canada's Heart and Stroke Foundation and The Lancet are among the many who have criticized the use of the "95% safer" claim.

A second look at the outcomes of Dr. Hajek's experiment.

The data presented in the table below shows a broader range of outcomes from Dr. Hajek's study, drawing data from the NEJM paper and also in a NIHR Health Technology Assessment report published in August, i.e.

• "The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group".   
• "Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants])"
• "19 participants in the NRT arm using NRT at 12 months ..."
• "173 participants in the e-cigarette arm using e-cigarettes at 12 months... "
• "Among the e-cigarette arm abstainers, two were using non-allocated NRT at 12 months, whereas in the NRT arm, nine [abstainers] were using non-allocated e-cigarettes."

(No information was found on the number of people who used both NRT and e-cigarettes. Even if they were some, the results presented below would not differ greatly.)

NRT performed twice as well as E-cigs at achieving nicotine abstinance.

These results support the following statements:

• Participants in the E-CIG group had almost double the success in stopping using cigarettes (18% vs 9.9%). This is as the media reported.
• Participants in the NRT group had more than double the success in ending nicotine use (7% vs. 3.2%). This is something the media failed to report. 
• Participants in the E-CIG group had a much higher risk of becoming dual users (25.1% vs. 15.2%). This is something that the media also failed to report.

Other important conclusions can also be drawn from these outcomes:

• For people trying to beat nicotine addiction, failure continues to overwhelm success. This should heighten concerns about increase uptake of nicotine use.
• Those who have the opportunity to use e-cigarettes, including those who are encouraged to use NRT instead, are much more likely to both smoke and vape than they are to only vape. This might dampen enthusiasm that those who try vaping will be able to switch completely.

Higher standards of evidence

Single clinical trials, no matter how well performed or reported, are not usually considered the strongest evidence base for decision making. That distinction is usually reserved for systematic reveiws of multiple studies.

In 2016 two systematic reviews of e-cigarettes as cessation aids were conducted. They did not come to the same conclusion.

One was by the Cochrane reviews (and Dr. Hajek participated in this review.) This panel focused on the results of 2 randomized clinical trials, and concluded that "There is evidence from two trials that ECs help smokers to stop smoking in the long term compared with placebo ECs." The quality of those studies was considered low, and Dr. Hajek's 2019 results will likely strengthen this conclusion in subsequent Cochrane reviews.

The other was a systematic review and meta analysis conducted by U.S. physician Dr. Sara Kalkhoran and Dr. Stanton Glantz.  They looked over the same literature field, and included the same 2 clinical trials as the Cochrane review had. In addition, they considered the results of 20 studies with control groups and other studies. The conclusions from this analysis were that rather than helping smokers quit,  e-cigarettes made it harder for them to do so. The "odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes."

A Canadian study involving more than 6,000 smokers was included in the Kalkhoran review, but not by the Cochrane team. It was conducted at CAMH, and eventually published both as a conference paper and as a journal article. Those would-be quitters who used e-cigarettes were less likely to succeed in quitting. "E-cig adoption seems to negatively affect cessation outcomes and provides no benefit as a harm reduction tool  ..." 

This year researchers at the Ontario Tobacco Research Unit published a review of "E-Cigarette Use for Smoking Cessation." They found "a wide range of results" and - while clearly open to the idea of using vaping as a cessation tool - nontheless reported that "In general, the scientific literature regarding the effectiveness of e-cigarettes as a smoking cessation aid remains inconclusive."

The Montreal Jewish General is leading a clinical trial on e-cigarettes as cessation devices, partnersing with several hospitals across Canada. Their results are not expected until next year.

Policy implications

Setting policy or clinical practice guidelines on the role of e-cigarettes is challenging in the messy real world of competing evidence, uncertainty, nuance and concious/unconcious bias. And that is before commercial influence and tobacco industry interference is added to the mix!

Currently, smokers who want to quit smoking have a variety of tools available to them, including a variety of licensed NRT therapies, non-licensed e-cigarettes, as well as proven and unproven behavioural supports that range from telephone counselling to hypnotherapy. None of the above has been the choice of most successful quitters.

Smokers (and those who pay for quitting programs) are entitled to know the benefits and the risks of the approaches on offer. In the case of e-cigarettes, Dr. Hajek's paper is presented as evidence that E-cigarettes are a better option than NRT. The same paper also provides evidence that NRT is a better option for those who want to overcome addiction and also for those who want to avoid the additional risks of dual use.

Public Health leaders strengthen their call for action on vaping

The power to speak 

Medical officers of health have special responsibilities and powers in the Canadian health system. Although they work for municipal, provincial and federal governments, many have the authority to speak out about health risks without having to get approval from elected officials.

Federal law, for example, gives Canada's Chief Public Health Officer, Dr. Theresa Tam, the specific authority to "communicate with the public ... for the purpose of providing information or seeking their views about public health issues." This authority continues even during an election period, when the rest of the public service is under 'caretaker' restrictions.

The advice of one Medical Officer of Health is worth noting. The combined advice of all 14 has even greater significance.

Senior MOHs from the provinces, territories and federal system work together through the Council of Chief Medical Officers of Health. This council has spoken out about vaping twice this year - first on April 11 and then again exactly six months later, on Friday October 11.

Comparing these two statements allows us to see how these physician leaders have deepened their understanding of the vaping problem and how they have changed their recommended approach to managing it.

A much-needed statement in April.

Vaping products were legalized in Canada in late spring of 2018, and it was not long before parents, teachers and communities were coming to grips with this new form of drug use. By late winter, the federal government was signalling that it was open to changing the law, but in a cautious way.

In April the Council of Chief MOH seemed willing to speak of the problem with more urgency than Ministers of Health were expressing. "We are seeing an alarming number of youth vaping in Canada," their statement read. "We cannot allow a new generation of Canadians to become dependent on nicotine and develop long-term risks to their health. We all have a role to play in protecting our youth.."

(How welcome this was for those who had been urging parliament to fix the problems with the federal law before the election, or even calling on the Minister of Finance to shoehorn an amendment into the Budget Bill.)

A strong stand in October. 

Only 10 days before the federal election, the Council issued its second statement on vaping. This time, its analysis of the problem had deepened and its call for action was more focused on regulators. In this statement, the Council goes much further than it did in April, and acknowledges for the first time that:

• vaping is a gateway to tobacco use 
• independent of tobacco use, vaping causes new public health challenges
• vapers inhale cancer-causing chemicals
• the compounds used in vaping products which are safe to eat (i.e. glycerol) may not be safe to inhale
• Canadians should refrain from using e-cigarettes or vaping products 
• vaping is not recommended for pregnant women or adults who do not currently use tobacco products. 
• laws on vaping products should include plain packaging, health warnings and regulations on the marketing and sale of products and flavurings. 

Just as noteworthy were the ideas contained in the April statement which were dropped this month:

• switching comipletely to vaping is a less harmful alternative to smoking.
• putting the onus on youth, adults and health educators to manage the problem of youth vaping before putting the responsibility on government.

In its October statement, the Council of Chief Medical Officers of Health is now calling for the same policy changes as health groups have been promoting since the introduction of S-5, the parliamentary bill which became the new Tobacco and Vaping Products Act.  Its warnings against using vaping products are stronger and clearer than those currently communicated to the public by Health Canada.  It has moved away from encouraging smokers to switch to vaping to one of encouraging vapers to quit.

Let's just hope that health ministers and ministries are listening!

Where 'leap frog' on vaping laws is needed, Yukon plays a slow game of 'catch up'.

This week Yukon introduced a bill to modernize its controls on vaping products. Bill No. 3, the "Tobacco and Vaping Products Control and Regulation Act" was introduced yesterday.

There are now only 3 provinces or territories - Saskatchewan, Alberta and Nunavut - that have failed to give regulatory acknowledgement to the public health challenges of vaping products.

A lot of has been learned in the four years since the first provincial laws were introduced. The 5 provinces east of Ontario legislated in 2015, as did Manitoba. These provinces deserve praise not only for being quick off the mark, but also for their foresight in imposing similar or the same rules on vaping as they did on tobacco producdts. (A fact sheet which compares provincial vaping regulations can be downloaded here).

For Yukon, however, it has taken some time to get there -- years since other provinces regulated and months since the views of Yukoners were canvassed this spring. (The brief "what we heard" brochure is dated in August, but was only released this week).

Yukon's new law, sadly, follows the most relaxed approach of to vaping reguations. It does not ban billboards or broadcast commercials for vaping products, as the laws in Quebec, Nova Scotia, PEI and Manitoba do. It does not ban the sale of these products on campuses or government buildings. It does not ban vaping in hotel rooms. There are no retail licensing requirements. The retail or manufacturing industry are not required to pay the costs of enforcement and inspection.

Given the recent evidence of new harms from vaping, and the concern about youth use, one might have expected Yukon to 'leap-frog' and propose more stringent measures than are currently in place in other provinces. They have not chosen this approach, but are instead proposing soft-touch regulations.

However, one measure in the Yukon bill stands out as a measure every jurisdiction should put in place. The law gives the government the power to require retailers to keep records and to make reports to government. With such a quickly moving problem as vaping, such information is much needed. (Similar authorities are in Ontario and Quebec laws, but have not yet been put to good use).

Let's hope Yukon's regulations strengthen this otherwise modest legislative proposal.

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:

* JUUL was hauled before Congress to answer questions about its marketing strategies, 

* top medical authorities issued unequivocal warnings that vaping products are "not safe" for non-smokers, 

* campaigns with powerful messages were launched to communicate the risks to teenagers. 

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.

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?

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 France, Germany and the United Kingdom.