Since 2009, Health Canada has enforced a ban on electronic nicotine delivery systems, known more commonly as electronic cigarettes or e-cigarettes. The agency cites the potential for nicotine poisoning and addiction as reasons for the ban. But that decision is hardly without controversy in the medical community. Some smoking cessation experts heartily support the ban, while others see a lost opportunity for harm reduction among smokers and oppose the ban.
On Friday January 24, as part of its 6th annual Ottawa Conference on smoking cessation, the University of Ottawa Heart Institute hosted an Oxford-style debate on the pros and cons of the Canadian e-cigarette ban, moderated by noted smoking cessation expert, Andrew Pipe, MD.
Arguing for the potential benefits of e-cigarettes—and against the current ban—was David Sweanor, adjunct professor of law at the University of Ottawa who has been involved with tobacco control legislation for more than 30 years. Despite such public health successes as smoking bans in public spaces, large graphic warnings on cigarette packages, restrictions on advertising, and substantial increases in tobacco taxes, these efforts have only succeeded in lowering the number of smokers in Canada from around 7 million to around 5 million, explained Sweanor. “That’s not a public health revolution,” he said.
It’s not that smokers don’t want to quit. It’s that they can’t, he argued. “We’ve been very good at motivating people to quit, but very bad at facilitating successful cessation.” He summed up the dangers of regular combustible cigarettes in four words: “It’s the smoke, stupid.” While nicotine is the addictive component of tobacco, it’s largely the byproducts of processing and burning tobacco that cause heart disease, cancer, and other health issues in smokers.
“If we can move people off of combustion-based delivery, give them nicotine in something far-less hazardous, we may have solved this issue,” said Sweanor, arguing that harm reduction for people intractably addicted to nicotine should be the primary concern in e-cigarette availability. However, he continued, if the public health community makes e-cigarettes as hard to acquire as nicotine replacement therapies (NRTs) such as the patch, people won’t have access and won’t make the switch. “We need regulation rather than a ban,” he concluded.
Jon Ebbert, MD, professor of medicine at the Mayo Clinic, disagreed, arguing that the ban is appropriate while the medical community gathers more data—not assumptions—about e-cigarettes. He explained that as a medical practitioner, he would never recommend a treatment to his patients without evidence that it works, and that this evidence is lacking for e-cigarettes as a smoking cessation aid.
Two recent clinical trials have shown the devices to be no better at facilitating quitting than standard NRTs, he recounted. And, concerning to him, is the fact that no regulations as to what additives and chemicals can be added to e-cigarettes currently exist, and no standards specify how much nicotine they can contain.
In addition, he cited evidence that e-cigarettes may be a “gateway” to tobacco use for non-smokers and that the majority of users are actually “dual users” who sometimes smoke e-cigarettes and sometimes smoke combustible tobacco. “The problem with dual use is that it undermines cessation attempts,” he explained. If people do not make the switch away from combustible tobacco completely, the purported health benefits of e-cigarette use would be largely moot. As an example, he cited research that 80 per cent of cardiovascular risk from smoking comes from less than one cigarette per day of exposure.
“So, I think that Canada’s got it right.We need to take the time to get the data out there, and then we need to make an informed decision based on the data that we’ve accumulated.” He described the e-cigarette situation in the United States as “the wild west,” with the devices widely available to consumers with little or no regulatory oversight.
During the question period, healthcare professionals in the audience noted that these products are already in the community, despite the ban. “I think you’re both right,” commented a nurse practitioner who fields frequent questions about e-cigarettes. “People are going to use them—we know they are. But we need to at least mitigate the risks, so we know people are using a form that at least is safe,” and assure that the regulations that already apply to regular cigarettes—such as no sales to minors—apply to e-cigarettes as well.