Position of Elgin St. Thomas Public Health

Transcription

1 Title: Approved by: E-cigarettes Cynthia St. John Executive Director, Dr. Joyce Lock Medical Officer of Health and The Board of Health Date Approved: November 4, 2014 Date Effective: November 4, 2014 Date Revised: January 8, 2017 Contact: Leigh Ann Darling, Health Promoter Position of Elgin St. Thomas Public Health 1. Until further evidence supports the use of an e-cigarette as an effective cessation device and regulations are put in place, Elgin St. Thomas Public Health will continue to promote and support the public with all quit attempts using legal, regulated nicotine replacement therapy (NRT) which includes the patch, gum, lozenges, inhaler, and quickmist. E- cigarettes are not yet regulated in Canada, so will not be promoted or distributed at any quit smoking programs supported by ESTPH. 2. E-cigarettes containing nicotine are currently illegal for sale in Canada. E- cigarettes that do not contain nicotine are legal for sale in Canada. 3. E-liquid containing high doses of nicotine can be toxic or lethal to children. 1 Caregivers that are using e-cigarettes with nicotine e-liquid should ensure they are kept away from children. 4. The short-term and long-term health effects of inhaling propylene glycol, the main ingredient in e-cigarette vapour are unknown. 2 Further scientific research is needed to determine any possible health effects of short-term and long-term use of e-cigarettes. 5. There is a risk of second-hand exposure to certain toxicants, nicotine, and ultrafine particles through the vapour emitted by e-cigarettes. 3 The amount of risk to bystanders remains unknown. 6. E-cigarettes have the potential to re-normalize smoking and act as a gateway to 1

2 traditional tobacco use among youth. Data is not yet available to determine the relationship between e-cigarettes and re-normalization or the effects of increased youth uptake of traditional tobacco, however the possibility should be considered. 7. E-cigarettes are being considered safer than conventional tobacco cigarettes as there is no tobacco or combustion involved in their use 4. E-cigarettes may have the potential to be used as a harm reduction tool if the appropriate regulations are put in place and further research is conducted. Canadian regulations around the sales, marketing, packaging, labelling, and ingredients of e-cigarettes and e-liquid are needed. 8. The use of e-cigarettes has created complications with enforcement of the Smoke- Free Ontario Act (SFOA) and smoke-free policies. The physical characteristics of an e-cigarette are extremely similar to a traditional cigarette. This can make it difficult for enforcement officers to differentiate if tobacco is being used in places where smoking is prohibited, such as inside buildings, work vehicles, in front of hospital entrances, and on school property. This enforcement challenge should be minimized by including e-cigarettes in smoke free policies and regulations. 9. Canadian regulations around the sales, marketing, packaging, labelling, and ingredients of e-cigarettes and e-liquid are urgently needed and should include: Manufacturing of all e-cigarettes, cartridges, and liquids are regulated using the same standards as other products under the Canadian Consumer Protection law. E-liquids are labelled with a list of ingredients along with the quantity of nicotine. E-liquids are sold in child proof containers. The advertising and promotion of e-cigarettes and related products are restricted to youth, in the same ways as tobacco. The sale of youth-friendly flavoured liquid is banned. The sale of e-liquids to minors is banned. Introduction: The original electronic cigarettes or e-cigarettes were designed to look and feel like real cigarettes. E-cigarettes currently on the market come in all different designs and sizes. E-cigarettes are battery powered and contain an atomizer that heats the liquid and turns it into a vapour that resembles smoke. They typically have one end that glows to resemble the tip of a cigarette. 1,5 E-cigarettes usually consist of three main parts: the delivery device, the cartridge and the refill solution. Cartridges contain a liquid (often referred to as e-liquid or e-juice) and contain water, propylene glycol flavouring, sometimes nicotine, and potentially other chemicals, such as acetaldehyde, formaldehyde, nickel, lead, and tolene. 6 Replacement cartridges and refill solutions are available with various doses of nicotine (usually 20 mg of nicotine but some can contain as much as 1 g of nicotine). 1, 7 Nothing prevents people from filling cartridges with other substances or more nicotine. 1, 7 2

3 E-cigarettes first entered the American market in Since then their use and availability has continued to increase. 5 On March 27, 2009; Health Canada issued a media advisory warning Canadians not to use electronic smoking products. The reasoning behind this advisory was that the devices have not been fully evaluated for safety, quality and efficacy. 8 Despite this advisory, a 2011 four country study illustrated that 10.1% of Canadians had tried using an e-cigarette. 9 Overall in 2015, 13% (3.9 million) of Canadians aged 15 years and older reported having ever tried an e-cigarette, an increase from 9% (2.5 million) reported in Twenty-six percent (26% or 534,000) of youth aged 15 to 19, and 31% (743,000) young adults aged 20 to 24 reported having ever tried an e-cigarette. Eleven percent (11% or 2.6 million) of adults aged 25 years and older said they have tried an e-cigarette. 10 Many organizations are taking a stance on e-cigarettes and there is a growing debate over their use. Some believe that e-cigarettes should be banned until further research verifies their safety and ability to help people quit smoking. Others believe that e- cigarettes are a clean drug delivery device that can help people quit smoking or simply receive nicotine without the combustion of smoking tobacco. Some examples of the stance that organizations have taken on e-cigarettes include: The Non-Smokers Rights Association (NSRA) has taken the position that e-cigarettes could help people quit smoking, should not be banned, and should follow the same regulations as tobacco. 4 Developing regulations is also highlighted as a first priority according to the WHO, stating, when designing a regulatory strategy for Electronic Nicotine Delivery Systems (ENDS), governments should bear in mind the following general regulatory objectives: o impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; o minimize potential health risks to ENDS users and non-users; o prohibit unproven health claims from being made about ENDS; and o protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. 3 The County of Elgin prohibited the use of e-cigarettes in all County buildings, noting that the health effects are still unknown. The County also took the renormalization of tobacco use into consideration. 11 The Canadian Lung Association is concerned with the unknown effects of inhaling unregulated and potentially harmful substances; the uncertainty of e- cigarettes being an effective cessation device, and the possible increase in uptake of tobacco use. 12 This association recommends that all laws related to smoke free areas include e-cigarettes. Elgin St. Thomas Public Health amended the Smoke-Free Workplace Policy to include e-cigarettes use inside ESTPH buildings. E-cigarettes with nicotine cannot be legally sold in Canada. In March 2009, Health Canada released a notice to all person interested in importing, advertising or selling e- cigarette products in Canada. The notice stated, electronic smoking products as well as cartridges of nicotine solutions and related products fall within the scope of the Food and Drugs Act. All of 3

4 these products require market authorization prior to being imported, advertised or sold in Canada. Market authorization is granted by Health Canada following successful review of scientific evidence demonstrating safety, quality and efficacy with respect to the intended purpose of the health product. This evidence is provided by the sponsor seeking market authorization. To date, no electronic smoking product has been authorized for sale by Health Canada. 13 E-cigarettes that make a health claim or are marketed as a cessation aid are also illegal to sell in Canada. However, due to a lack of enforcement, e-cigarettes containing nicotine are widely available. 14 The Canadian Cancer Society-Quebec Division, commissioned a study of thirteen different e-cigarette products. Findings showed that two-thirds of the products labelled nicotine-free, contained nicotine. 15 Rationale: Smoking Cessation Presently, there is limited evidence to support e-cigarettes as an effective cessation aid. Although it is noted that there are some studies that have begun to show e-cigarettes as a promising cessation device. For example, another study conducted by Brown et al. looked at the real-world effectiveness of e-cigarettes as a cessation device. Between 2009 and 2014, 5,863 smokers were surveyed who had attempted to quit smoking. Twenty percent of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes at the time of the survey. 16 However, a background paper on e-cigarettes prepared for the World Health Organization in December 2013, concluded that, population-based longitudinal studies that reflect realworld e-cigarette use found that e-cigarette use is not associated with successful quitting. 6 A 2016 Cochrane Review involving 24 studies concluded that there is evidence that e-cigarettes help smokers to stop smoking in the long term. However, as with the previous Review, the authors confidence in this conclusion remains low owing to the fact that just 2 randomized control trials (RCTs) the gold standard of evidence were eligible for inclusion. Although the trials were deemed to be at a low risk of bias and the other studies were well designed and conducted, there simply aren t enough of them yet to comprise a robust body of evidence. 17 We do know that unassisted quit attempts are successful only 3-5% of the time, compared with up to 20% success rate for those receiving cessation counselling and medications, which include NRT and pharmacotherapy. 18 Studies have shown that the likelihood of a smoker quitting increased by 50-70% when using NRT. 18 For this reason, studies need to continue on the effectiveness of e-cigarettes as a recommended form of NRT. Many studies have identified the main reasons people are choosing to use e-cigarettes are to either help them quit smoking or to replace the use of tobacco. 6 Several e- cigarette companies are making claims that e-cigarettes are safer and healthier than 4

5 smoking traditional tobacco. 19 One website claims, Stay healthy, live longer, make the switch to e-cigarettes. 19 For this reason, the public believes that e-cigarettes are healthier than regular cigarettes, dismissing the possible negative health effects. 20 More research needs to be done to understand the 'attitudes and beliefs' as well as efficacy surrounding e-cigarettes as a viable smoking cessation aid. Health and Safety There has been little conclusive evidence to assess the short-term and long- term health effects of e-cigarette use. Propylene glycol has been considered safe for oral consumption; however, the long-term risks associated with the inhalation of propylene glycol are unknown. 2 Some research has shown that the most common side effects related to e-cigarettes are generally associated with the inhalation of propylene glycol and consist of "dry mouth, throat irritation, dry cough, and nose bleeds." 21 A study has also shown that when propylene glycol is heated and vapourized, cigarettes are associated with increased levels of formaldehyde and acetaldehyde in the vapour. 2 Due to the limited amount of time that e-cigarettes have been available and used, the long-term health effects of using an e-cigarette remain unknown. Due to the lack of regulation around sales and labeling of e-liquid, consumers are often unaware of the ingredients and nicotine dosages. For example, the NSRA reported that one distributer in London, Ontario mixes the e-liquid in his basement and even asks customers to return the vials for refilling or recycling. 14 Similar to traditional tobacco second-hand smoke, e-cigarettes also produce a vapour that when exhaled could pose a risk to bystanders. Research has begun to show that the water vapour that is exhaled is not composed of merely water. Certain levels of toxicants, nicotine, and ultrafine particles have been described. 3 One study has also found that individuals who were exposed to second-hand vapour demonstrated the same levels of nicotine absorption in their blood as those individuals exposed to second-hand smoke. 22 It is unknown at this time if the increased exposure to the identified particles will lead to increased risk of disease. More research is needed to examine the health risks associated with exposure to second-hand vapour. E-liquid has been shown to contain anywhere between 1-20 mg or greater of nicotine. 1 The estimated lethal dose for a child is 10 mg. 1 In August 2014 the Centre of Disease Control and Prevention released a report that showed a dramatic increase in U.S. nicotine related poisonings, from 1 per month in 2010 to 215 per month in February Fifty-one percent of the calls involved children under the age of five years. 23 E-cigarettes are, however, being acknowledged for containing no tobacco and involve no combustion, therefore pose substantially less risk to health than smoking traditional cigarettes. 21 Although the available research suggests that e-cigarettes have the potential to reduce the number of traditional cigarettes smoked, often individuals continue to use both the e-cigarette and traditional tobacco together. 3 5

6 While there is potential for smokers to reduce their traditional cigarette consumption by using an e- cigarette, at this point in time studies have indicated that continuing to smoke any amount of traditional tobacco still poses relatively the same cardiovascular and cancer risks. 3 Youth E-cigarette Use Re-normalization A major concern surrounding the e-cigarette industry, in addition to its effect on youth uptake of e-cigarettes, is the potential for e-cigarettes to act as a gateway to traditional cigarette use. The 2013 Ontario Student Drug Use and Health Survey showed that 14.6% of students in grades 9-12 reported using a cigarette in their lifetime. 2 This represents approximately 99,800 students in Ontario. 2 A recent paper also showed that in Canada, 10% of non-smoking youth ages reported using an e-cigarette. 25 Evidence has been shown that the use of nicotine has potential negative impacts on adolescent brain development. 26 Another 2013 study looked at the social norms and beliefs of male teenage e- cigarette use. The research concluded that the most common reasons for using an e- cigarette included the following: they are accessible, healthier than tobacco cigarettes, and more aesthetically pleasing. 27 Much of this perception can be attributed to the rapid market penetration of e-cigarettes among youth. 6 It has been shown that more than half of Canadian youth, grades 9-12, who use tobacco, use a flavoured product. 28 The use of youth friendly packaging and flavours such as Bubble Gum, Snickerdoodle, and Sweet Tarts is a major marketing and promotion strategy of the e-cigarette manufacturers. 14 This can also link back to the increased number of nicotine poisonings among children under five years. 23 E-cigarette marketing strategies are showing similar advertising tactics as traditional cigarette companies before regulations took place in The use of Hollywood celebrity endorsements, free product, provocative advertisements in magazines and social media, and the use of attractive flavours and packaging are arguably all tactics to target sales to youth and re-normalize the act of smoking. 14 Although there is limited evidence to date to support the thought that e-cigarettes could lead to traditional tobacco use or that smoking could be re-normalized, this possibility should be considered. Enforcement & Regulation The sale of e-cigarettes containing nicotine is currently banned in Canada, along with the advertisement of e-cigarettes that make a health claim. There are currently no other regulations around the marketing, labelling, sale of e-liquid to minors, safe packaging, promotion or sponsorship. As many organizations are taking a stance on e- cigarettes, a common theme emerges around the important need for regulations. The World Health Organization, Non-Smokers Rights Association (NSRA), Heart and Stroke Foundation, various Public Health Units, and the Association of Local Public Health Agencies, to name a few, have made recommendations for strict regulations similar to the following: 6

7 Manufacturing of all e-cigarettes, cartridges, and liquids are regulated under the same standards as other products under the Canadian Consumer Protection law. E-liquids are labelled with a list of ingredients along with the quantity of nicotine. E-liquids are sold in child proof containers. The advertising and promotion of e-cigarettes and related products are restricted in the same ways as tobacco. The sale of youth-friendly flavoured liquid is banned. The sale to minors is banned. With no regulations currently applying to e-cigarettes, enforcement of the SFOA can become challenging for Tobacco Enforcement Officers (TEO). The NSRA has reported that in Ontario, there have already been cases where a person charged under the SFOA, claimed using an e-cigarette not a traditional cigarette. 14 With almost the identical appearance to tobacco cigarettes, some e-cigarettes are extremely challenging to identify as such. This concern could merit the prohibition of e-cigarettes where all traditional tobacco is currently prohibited. Implications for Elgin St. Thomas Public Health Elgin St. Thomas Public Health will: 1. Continue to support clients who are making a quit attempt through the use of recommended and regulated Nicotine Replacement Therapy through communitybased partnerships and STOP on The Road workshops. 2. Include cautionary messages to parents around the use of e-cigarettes and e- liquids in parenting resources, programs and services. 3. Continue to evaluate new research as it becomes available and review the organization s position on e-cigarettes as necessary. 4. Advocate to Health Canada and the Ministry of Health and Long-Term Care that e- cigarettes must be regulated and enforced as a tobacco product and that they be included in the SFOA, until further research supports otherwise. 5. Encourage citizens to report e-cigarette sales, advertising that contains nicotine or make a health claim to Health Canada at

8 References: 1. Cobb, N. K. & Abrams, D. B. (2011). E-cigarette or drug delivery device? Regulating novel nicotine products. The New England Journal of Medicine, 365(3), Kosmider, L., Sobczak, A., Fik, M., Knysak, J., Zaciera, M., Kurek, J., & Goniewicz, M. L. (2014). Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage. Nicotine & Tobacco Research, ntu World Health Organization, (2014). Electronic Delivery System Report. Retrieved September 25, 2014 from: en.pdf?ua=1 4. Non-Smokers' Rights Association/Smoking and Health Action Foundation (2013, June). Position Statement on Electronic Cigarettes. Retrieved September 15, 2014 from: 5. Canadian Public Health Association. (winter 2013/2014). Policy Brief: E-cigarettes A smoking problem? CPHA Health Digest. Retrieved from: 6. Benowitz N., Glantz S.A., Grana R. (2013). Background Paper on E-cigarettes (Electronic Nicotine Delivery Systems) Prepared for the World Health Organization Tobacco Free Initiative. Retrieved from: 7. Riker, C. A., Lee, K., Darville, A., & Hahn, E. J. (2012). E-Cigarettes: Promise or Peril? Nursing Clinics of North America, 47 (1), Health Canada (2009). Health Canada Advises Canadians Not to Use Electronic Cigarettes, Media Advisory. Retrieved from: avis/_2009/2009_53-eng.php 9. Adkison, S.E et. al. (1993). Electronic nicotine delivery systems: international tobacco control four-country survey. American Journal Prevention Medical, 44(3), Government of Canada (2016). Canadian Tobacco, Alcohol and Drugs Survey (CTADS) Summary of Results. Retrieved from: County of Elgin (2014). Smoking in the Workplace Policy. Human Resources Policy Manual.#

9 12. The Lung Association (December, 2012) The Canadian Lung Association s Position Statement on Electronic Cigarettes (E-Cigarettes) Retrieved from: Health Canada. (2009). Notice - To All Persons Interested in Importing, Advertising or Selling Electronic Smoking Products in Canada. Retrieved from: Non-Smokers Rights Association (2012). The Buzz on E-Cigarettes. Retrieved from: 15. Canadian Cancer Society- Quebec Region. (September 2013). Press Release: The Canadian Cancer Society s lab tests and exclusive survey: Electronic cigarettes have misleading labels and are gaining popularity among youths. Retrieved from: media/mediareleases/quebec/2013/la-cigarette-electronique-est-etiquetee-de-facontrompeuse/?region=qc 16. Brown J., Beard E., Kotz D., Mitchie S., and West R. (2014). Real-world effectiveness of e- cigarettes when used to aid smoking cessation, A crosssectional population study. Addiction 2014 Sep; 109 (9): Smoking and Health Action Foundation (September, 2016). E-Cigarettes: An Update. Retrieved from: U.S. Department of Health and Human Services: Office of the Surgeon General (2008). Tobacco Cessation You Can Quit Smoking Now! Retrieved from: Stead L.F., Perera R., Bullen C., Mant D., Lancaster T. (2008). Nicotine replacement therapy for smoking cessation (Review) The Cochrane Collaboration 20. Pepper K. Jessica & Brewer, T. Noel (2013). Electronic nicotine delivery system (electronic cigarettes) awareness, use, reactions and beliefs: a systematic review. Tobacco Control (051122), Non-Smokers Rights Association (2013). E-Cigarettes: Understanding the Potential Risks & Benefits Retrieved from: Cig_Fact_Sheet_NSRA_17Oct13_final.pdf 22. Flouris, A. D., Chorti, M. S., Poulianiti, K. P., Jamurtas, A. Z., Kostikas, K., Tzatzarakis, M. N.& Koutedakis, Y. (2013). Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhalation toxicology, 25(2),

10 23. Centers for Disease Control and Prevention. (2014). Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes United States, September 2010 February Retrieved from: 6313a4_w 24. Boak, A., Hamilton, H. A., Adlaf, E. M., & Mann, R. E. (2013). Drug use among Ontario students, : Detailed OSDUHS findings (CAMH Research Document Series No. 36)Toronto, ON: Centre for Addiction and Mental Health. 25. Shiplo S, Czoli C, & Hammond D. (2013) E-cigarettes in Canada: Prevalence and patterns of use. The Program Training and Consultation Centre (PTCC). 26. Dwyer, J. B., McQuown, S. C., & Leslie, F. M. (2009). The dynamic effects of nicotine on the developing brain. Pharmacology & therapeutics, 122(2), Abughosh S., Hill M., Lin M., Meshack A., & Peters R.J. (2013) The social norms and beliefs of teenage male electronic cigarette use Journal of Ethnicity in Substance Abuse 12: Minaker L. M., Ahmed R., Hammond D., & Manske S (2014). Flavored Tobacco Use Among Canadian Students in Grades 9 Through 12: Prevalence and Patterns From the Youth Smoking Survey. Prev Chronic Dis,