Mark Tyndall’s Submission to the BC Ministry of Health Protection Branch

Dear Ministry of Health:

I would like to provide some comments on the new regulatory framework presented by the Ministry of Health under the Tobacco and Vapour Products Control Act (TVPCA) that was put out for public consultation. These are my own thoughts and do not necessarily represent the views of UBC. In addition, I have recently acted as an expert consultant on harm reduction to VITA (Vaping Industry Trade Association). This letter is not part of that consultation and does not necessarily represent the views of VITA.

I am a public health physician and was the Executive Director of the BC Centre for Disease Control and a Deputy Provincial Health Officer working under Dr. Perry Kendall from 2014-2018. My work has focused on harm reduction as it relates to other drugs in society but I have been advocating for the promotion of vaping as a harm reduction intervention for cigarette smoking since 2012 through research, opinion pieces, consultations and as an expert witness in court cases. Mostly I have seen the very worse that cigarettes can do through over 30 years of clinical practice and strongly believe that vaping is the single most significant health intervention that I have seen in my medical career.

In response to an “epidemic” of vaping among youth, the province of British Columbia has released a new set of regulations designed to reverse this trend. It aims to position the government as a progressive champion for the health and well-being of young people and has been widely applauded by anti-smoking groups.  As other provinces tackle the same issues it is likely that similar legislation will be enacted across Canada.  While vaping has been increasing among youth since 2015, the impetus to act now has been driven by the recent outbreak of over 2,000 cases of vaping related lung diseases in the United States, including 42 deaths. While there have been no reported deaths in Canada, there have been 6 reported cases of vaping associated illnesses the details of which have not been released.

Public health officials at the Centers for Disease Control in the US have been extremely cautious in reporting out the cause of these acute lung injuries and for several months would only say that vaping should be avoided until investigations were complete.  It is now clear that these illnesses had nothing to do with vaping commercially available nicotine-containing e-cigarettes. At the outset over 90% of the patients self-reported vaping THC and it was recently shown that 29 of 29 lung fluid specimens collected showed vitamin E acetate which has been an additive in THC vaping pods. Vitamin E acetate or other oils are not found in standard nicotine-containing vaping liquids.

This tragic outbreak is a problem of illegal, boot-leg THC vaping pods that is driven by lax regulation, misinformation and uneven cannabis legislation across the US.  Since these illnesses are unrelated to youth vaping in general, the regulations introduced in BC will not directly prevent any new cases of acute lung injury.  In fact, prohibition invites alternative supply sources as seen in the US and the unintended consequences could actually be an upswing of cases.

What is most problematic with this announcement is that it does not even mention the major potential of vaping as a harm reduction strategy to reduce the suffering and death caused by cigarettes. Even before the outbreak of lung disease in August of 2019, the voice and interests of smokers was largely ignored. Public health officials clung to the thinnest of arguments against the benefits of vaping over smoking cigarettes and essentially gave people the green light to continue smoking. How can a technology that allows people to use nicotine while essentially eliminating exposure to all of the known toxins and carcinogens be met with so much scepticism and opposition?

Ironically, many of the institutions and individuals speaking out the loudest against vaping do support other harm reduction measures like seatbelts and airbags to reduce traffic fatalities, designated driver programs to reduce impaired driving, bicycle helmets to reduce head injuries, condoms to prevent the transmission of sexually transmitted infections, and even needle exchange programs to reduce the transmission of HIV among people injecting drugs. These are pragmatic and common-sense approaches that reduce the risk of harm when engaging in activities that carry some degree of inherent risk. However, this standard public health approach has not been applied to vaping even though the direct health and societal impacts of cigarette smoking are far greater than all these other issues combined.

At the core of the opposition to vaping is the belief that we are actually doing a good job at helping people to quit smoking cigarettes. This is so far from the truth. The overall slow reduction in smoking prevalence seen in Canada is directly related to the relentless and predictable death of current smokers along with a reduction in smoking initiation by young people. Current smokers, most of whom have tried and failed to quit with the available interventions, have been left to either quit on their own or die prematurely. The impact of smoking related illness has fallen disproportionately on people living in poverty, people with mental illness, and those dealing with other substance use challenges, where the rates of smoking are extremely high and the chance of quitting is extremely low.

Today alone, 100 Canadians will die directly and prematurely from smoking cigarettes. This is the public health emergency, not vaping. Any new legislation that restricts vaping without addressing cigarettes only serves to benefit tobacco sales and the companies that profit from it. Transitioning people from cigarettes to vaping should be the centre piece of our tobacco-free aspirations in Canada. Many people will be able to quit vaping nicotine overtime, but getting off cigarettes, the most dangerous nicotine delivery method known, should be the priority. In order to encourage this transition, vaping products must be incentivised for current smokers. This includes accurate information, lower cost, choice of flavors, and adequate nicotine dosing. This all can be done while discouraging the uptake of vaping among young non-smokers through education, youth-oriented promotional restrictions, and other measures to reduce youth access.

I would like to comment on the 6 proposed regulatory changes specifically.

1. Prescribe Nicotine as a “Health Hazard”. There is very little evidence that nicotine itself is a health hazard.  Clearly it is addictive and is directly responsible for the continued use of cigarettes. Several high-profile cases of infants drinking e-liquid have appeared in the media but this is no different than infants getting into medications or house-hold cleaning products.  Nicotine is a mild stimulant that can transiently raise blood pressure, but nicotine does not cause cancer or heart disease or lung disease. It has been shown in animal studies to impair normal brain development in the developing brain but the application to humans is unknown.  Obviously reducing/eliminating exposure of nicotine in youth is a prudent approach but putting a skull and cross-bones on any nicotine product or calling it poison is not based on evidence and certainly not what we have seen over many decades of nicotine exposure by the millions of cigarette smokers in Canada.
2. Restrict Nicotine Concentration in Vapour Products. One of the attractions of vaping for youth is the “jolt” of nicotine that they receive. Limiting access to liquids that contain a high concentration of nicotine to youth is prudent.  However, the whole philosophy of harm reduction – especially for transitioning cigarette smoking to vaping – is based on the ability to provide the necessary amount of nicotine. Someone consuming 2 packs of cigarettes a day may indeed require a higher concentration of nicotine. Failure to do this will lead to frustration with vaping and for many people dual use. Just having a blanket maximum level will reduce uptake among heavier smokers and directly lead to black-market products or home-brew solutions that cannot be regulated and could be dangerous.
3. Restrict the Sale and Distribution. There needs to be a regulatory framework in place at the point of sale – including the internet. This is in the best interest of public health, the consumer and the seller. The regulations as written seem reasonable but as with other substances (i.e. alcohol, cannabis), the challenge is enforcement and better age verification technologies would be helpful.
4. Restrict the Sale of Flavoured Vapour Products. This is probably the most contentious issue. Perhaps the biggest motivation for cigarette smokers to transition to vaping is flavours. The vast majority of cigarette smokers do not like tobacco flavour. Most retailers report that over 90% of their sales are flavoured products. It will be fine to restrict the sale of confectionary named flavours but will do little to determine what is in the actual liquid. I think that some basic flavours should be available in Class 1 vapour product retailers or essentially 90% of vapers will not be able to purchase what they are using from these Class 1 sites.  Enforcing age-restrictions should be the main tool to prevent youth uptake at Class 1 outlets and not restricting all flavours. Just offering tobacco flavor is essentially useless for most vapers.
5. New Labelling. Consumers certainly need and deserve accurate information around the content of the e-liquids. However, the contents are not “poisonous”.  Obviously like any liquid it could be poisonous if swallowed in large enough quantities – like many medicinal products.  We don’t put poison stickers all over Tylenol packages. While proper warnings are fine, calling it poison is disingenuous and will scare some cigarette smokers away from vaping. We don’t even put “poison stickers” on cigarettes.  We want to incentivize smokers to take up vaping so plain packaging will be a disincentive.  By introducing plain package cigarettes while allowing some more attractive packaging for vape products would help to incentivize vaping.
6. Strengthen Restrictions of Public Advertising. These restrictions for youth seem reasonable.  Unfortunately, one of the best ways that we have for adult smokers to switch would be pressure from their children.