Tobacco harm reduction

by Kellie Ann Forbes | May ,Thu, 2021 | education, health professionals

Tobacco harm reduction

Smokers who aren’t willing or simply cannot quit smoking face a future of pain and suffering⁵⁰. As health professionals, you have a responsibility to help these people with the best available strategies to improve health outcomes⁵¹.

Learn how smokers are made

The biggest myth: there isn’t enough evidence

Health professionals are busy people, working long shifts in high stress environments. We understand that research is the last thing you want to do on your days off. VAEP was developed to make learning about tobacco harm reduction easy for health professionals and the public. This image is a screen shot from a medical data base. The search results for “e-cigarettes or vaping or vape or electronic delivery systems” provided over 22,000 published articles on vaping.

Eliquids are regulated

Keeping harm reduction safe

“If you are a smoker, vaping is a less harmful option than smoking.” Health Canada⁴¹. In May 2018, the Tobacco and Vaping Products Act came into effect and regulates eliquid manufacturing⁴². The government limits what can be put into eliquids to promote safety⁴².

Myth 2

We don’t know if vaping is less harmful than smoking

The multiple-criteria decision analysis (MCDA) is a decision-making tool that takes into account multiple factors and enables comparison of related subjects. Twelve experts compared sources of nicotine using 14 criteria of harm. Cigarettes are the most harmful source of nicotine at 100%. Vaping was assessed at less than 5% the harm⁵².

Myth 3

Second hand vapour is dangerous

Over 9000 observations of the constituents of vapour were compared to universally recognized workplace exposure standards known as Threshold Limit Values (TLVs). All constituents were valued at <1% TLV, except two constituents acrolein amd formaldehyde were <5%⁵³. It’s important to note that acrolein and formaldehyde are normal constituents of exhaled breath⁵⁴.

Myth 4

Nicotine causes disease

Nicotine is an addictive mild stimulant. It elevates mood, stimulates cognitive function and increases energy⁵⁵. It’s physiological effects and therefore addictive effects are similar to caffeine⁵⁶. It is not a carcinogen and without the adjunct chemicals, nicotine presents as less additive than cigarette smoke⁵⁵. Nicotine is so safe you don’t need a prescription or to be age of majority to buy nicotine patches, gums etc.

Further

The Royal College of Physicians (RCP)

RCP has been an authority in medicine for 500 years. ‘Nicotine without Smoke’, released by RCP in 2016, is a 200+ page report investigating the scientific research on vaping. Some of their key recommendations: “… the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco…in the interests of public health it is important to promote the use of e-cigarettes⁵⁷…”

Myth 5

Vaping is a gateway to smoking

During the last 6 years, vaping has been mainstream in Canadian society⁵⁸. This is the first generation of youth that have experimented with vaping⁵⁸. It is normal adolescent behavour to experiment with adult taboos⁵⁹. 20% of youth have tried vaping in the last 30 days⁶⁰. If vaping was a gateway to smoking we would observe an increase in youth smoking prevalence. As per the biennual Canadian Student Tobacco and Drug Survey, grade 12 smoking prevalence has decreased 63% in the last 6 years^58,60.

Further

The Canadian Institute for Substance Use Research

at the University of Victoria released in January 2017 ‘Clearing the Air: a systematic review of the harms and benefits of e-cigarettes and vapour devices’⁶¹. Tim Stockwell, an investigator on this review, stated: “The public has been misled about the risks of e-cigarettes. Many people think they are as dangerous as smoking tobacco but the evidence shows this is completely false⁶².”

Myth 6

Flavours are to attract youth

Considering that one in four Canadians are obese, and that alcohol comes in thousands of flavours we can deduce that adults like flavours⁶³. This is why nicotine gum, lozenges and sprays come in flavours⁶⁴. When smokers are detoxing off the 7000 chemicals found in cigarette smoke and transitioning to just pharmaceutical grade nicotine, pleasing flavours encourage continuation of harm reduction⁶⁵. Further, the novelty of flavours encourages the continued compliance with vaping⁶⁵.

Myth 7

Vaping’s ineffective for cessation

Considering that Canadian public health officials have utilized millions of our tax dollars to only oppress tobacco harm reduction by disseminating fear-based narratives about vaping⁶⁶, the vaping industry has been driven solely by consumer demand; smokers’ demand for an alternative that reduces harm⁶⁷. If vaping was ineffective it would not exist. From 2015 to 2017, the preferred smoking cessation method for Canadian smokers was vaping at 32% vs 24% with patches and 16% with gum⁶⁸. In the United States, 54% of successful smoking cessation attempts were with vaping⁶⁹.

Further

Controlled clinical trials

In 2014, smokers that did NOT want to quit smoking were given eliquid and vape pens (which aren’t as effective at nicotine delivery as the current devices). At 2 months, 34% of the subjects reported smoking cessation. eCO levels decreased significantly and continine (nicotine metabolite) remained the same. At six months, 21% remained exsmokers compared to 6% cessation with patches⁷⁰.

Myth 8

Approved cessation methods are effective

Prior to vaping, only 2.5% of smokers quit long term even though 52% attempted cessation annually^71,72. They had a 4% success rate with cold turkey; 8% success with nicotine replacement therapy (NRT) such as patches or gum; if adjunct counselling was added, success can reach 16%^71,73. Smoking cessation methods currently approved by Health Canada have an 84% failure rate at best! Of those successful ‘quitters’ 80% relapsed in the first month⁷⁴. Psychoactives have adverse effects such as suicidal ideation, violent outbursts, depression and psychotic episodes⁷⁵.

Myth 9

Vaping is ineffective for smoking cessation

A significant aspect of smoking is the ritualistic behaviour of bringing a smoke to the mouth; tasting the smoke with a drag; feeling sensations in the throat and lungs with a full inhale; and observing the visible exhale⁷⁶. The behaviour is repeated 240 times a day for a pack-a-day⁷⁶ smoker; 87,600 times a year! This physical ritual is coupled with an immediate increase in serum chemicals⁶¹. Further, smokers are proficient at maintaining therapeutic nicotine serum levels through inhalation⁷⁷. Vaping uniquely satisfies this ritual and provides nicotine through the same route⁷⁶.

Myth 10

Dual user isn’t quitting smoking

Utilizing vaping to transition from the most addictive product in Canada to nicotine-free is a process consisting of 4 stages⁶¹. The first stage is dual use which is when the smoker becomes familiar with how to use their vaping device to achieve therapeutic nicotine serum levels⁶¹. This may include trying different devices and eliquids to find what is right for them⁷⁸. Stage two is smoking cessation and continued vaping⁶¹. Invariably, after a few months to adjust to the decrease of serum chemicals, vapers decrease their nicotine dose and some then titrate off of nicotine completely⁶¹.

Listen to the experts

Quotes from those that have done the research

“The most important

toxins in cigarette smoke are missing – those that remain are orders of magnitude lower.” Dr. Konstantinos Farsalinos

“Vapers should

be more concerned of the air they breathe in polluted cities rather than their vaping!” Dr. Riccardo Polosa

“Saying e-cigs

are 95% safer is not a medical claim, it’s a truth.” Professor Hajek

“People smoke

for nicotine but they die from the tar.” Professor Michael Russell, 1976

Dr. Konstantinos Farsalinos

“The most important toxins in cigarette smoke are missing – those that remain are orders of magnitude lower.”

Riccardo Polosa

“Vapres should be more concerned of the air they breathe in polluted cities rather than their vaping!” Dr.

Professor Hajek

Saying e-cigs are 95% safer is not a medical claim, it’s a truth.”

Professor Michael Russell, 1976

“People smoke for nicotine but they die from the tar.”

Next section: bioethics

50. Polosa, R., Rodu, B., Caponnetto, P., Maglia, M., & Raciti, C. (2013). A fresh look at tobacco harm reduction: the case for the electronic cigarette.

51. Canadian Nurses Association. (2017). Code of ethics for registered nurses.

52. Nutt, D. J., Phillips, L. D., Balfour, D., Curran, H. V., Dockrell, M., Foulds, J., Fagerstrom, K., Letlape, K., Milton, A., Polosa, R., Ramsey, J., & Sweanor, D. (2014). Estimating the harms of nicotine-containing products using the MCDA approach.

53. Burstyn, I. (2014). Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks.

54. Filipiak, W., Ruzsanyi, V., Mochalski, P., Filipiak, A., Bajtarevic, A., Ager1, C., Denz1, H., Hilbe W., Jamnig, H., Hackl, M., Dzien, A., & Amann, A. (2012). Dependence of exhaled breath composition on exogenous factors, smoking habits and exposure to air pollutants.

55. Laugesen, M. (2013). Nicotine and health. New York, NY: American Council on Science and Health.

56. Royal Society for Public Health. (2015). Nicotine “no more harmful than caffeine”.

57. Royal College of Physicians. (2016). Nicotine without smoke: Tobacco harm reduction: A report by the Tobacco Advisory Group of the Royal College of Physicians.

58. Government of Canada. (2015). Canadian Student Tobacco, Alcohol and Drugs Survey.

59. Jackson, C. A., Henderson, M., Frank, J. W., Haw, S. J. (2012). An overview of prevention of multiple risk behaviour in adolescence and young adulthood.

60. Government of Canada. (2019). Canadian Student Tobacco, Alcohol and Drugs Survey.

61. O’Leary, R., MacDonald, M., Stockwell, T., & Reist, D. (2017). Clearing the Air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. Victoria, BC: Centre for Addictions Research of BC.

62. University of Victoria: UVic News. (2107). Clearing the air around e-cigarettes. Retrieved Feb. 19, 2020 from https://www.uvic.ca/news/topics/2017+e-cigarettes-carbc-macdonald-stockwell+media-release

63. Statistics Canada. (2017). Canadian Health Measures Survey.

64. Aslani, A., & Rafiei, S. (2012). Design, formulation and evaluation of nicotine chewing gum.

65. Russell, C., McKeganey, N., Dickson, T., & Nides, M. (2018). Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA.

66. Government of Canada. (2019). The risks of vaping.

67. Institute of Economic Affairs. (2013). Free market solutions in health: The case of nicotine.

68. Government of Canada. (2017) Canadian Tobacco, Alcohol and Drugs Survey (CTADS).

69. Farsalinos, K., Polosa, R., Cibella, C., & Niaura, R. (2019). Is e-cigarette use associated with coronary heart disease and myocardial infarction? Insights from the 2016 and 2017 National Health Interview Surveys.

70. Adriaens, K., Van Gucht, D., Declerck, P., & Baeyens, F. (2014). Effectiveness of the electronic  cigarette: An eight-week Flemish study with six-month follow-up on smoking reduction,  craving and experienced benefits and complaints.

71. Nides, M., Leischow, S.J., Bhatter, M., & Simmons, M. (2014). Nicotine blood levels and short-term smoking reduction with an electronic nicotine delivery system.

72. Polosa, R., Rodu, B., Caponnetto, P., Maglia, M., & Raciti, C. (2013). A fresh look at tobacco harm reduction: the case for the electronic cigarette.

73. Shahab, L., Brose, L.S., & West R. (2013). Novel delivery systems for nicotine replacement therapy as an aid to smoking cessation and for harm reduction: Rationale, and evidence for advantages over existing systems.

74. Polosa, R., Rodu, B., Caponnetto, P., Maglia, M., & Raciti, C. (2013). A fresh look at tobacco harm reduction: the case for the electronic cigarette.

75. Institute for Safe Medication Practices. (2008). QuarterWatch Report: Strong Safety Signal Seen for Chantix (Varenicline).

76. Dawkins, L. (2013). Why is it so hard to quit smoking?

77. Farsalinos, K., Spyrou, A., Tsimopoulou, K. et al. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices.

78. Farsalinos, K., Spyrou, A., Stefopoulos, C. et al. Nicotine absorption from electronic cigarette use: comparison between experienced consumers (vapers) and naïve users (smokers).

current context

by Kellie Ann Forbes | Mar ,Mon, 2020 | education, health professionals

The current context

The current resistance about tobacco harm reduction is a familiar reaction.

A similar response occurred during the AIDS crisis in the 1980’s.

The rhetoric at that time was that distributing condoms would encourage youth to become promiscuous²⁸.

Canadian Nurses Association harm reduction resources

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Stay current in the credible evidence

Tobacco harm reduction hx

The neo-prohibitionist approach to smoking is “Quit smoking or suffer and die from smoking-related diseases.” All innovative products under this precautionary principle are oppressed which supports the tobacco industry by denying the population safer alternatives and supports the pharmaceutical industry by promoting the incidence of smoking-related diseases. About 95% of unaided smoking cessations attempts end in failure and attempts with nicotine replacement therapies (NRTs) have <10% success rate at six months²⁹.

Snus is an oral tobacco product processed via fermentation which removes the tobacco-specific nitrosamines (the carcinogens found in tobacco). Due to pressure from public health groups, in 1992, the sale of snus was prohibited in the European Union (EU) despite the EU’s acknowledgement that snus is not a carcinogen. Sweden obtained an exemption to allow their smoking citizens a harm reduction option²⁹. As a result, Sweden has the lowest smoking rates and the lowest rates of lung cancer in the EU. It’s notable that 13% of Swedish men are smokers compared to an average 29% of men in the EU. Further, Sweden has the lowest rate of tobacco-related mortality even though Sweden consumes the same amount of tobacco by weight as other countries²⁹.

This is an example of the efficacy and sensibility of tobacco harm reduction (THR). History also illustrates the oppression of tobacco harm reduction by authority²⁹.

nicotine eliquid didn’t cause lung injuries

The recent outbreak of vaping-related lung injuries were a result of illegal THC (cannabis) cartridges used in vaping devices^30,31,32. Vitamin E acetate has been identified as the primary causative agent^33,34.

During the outbreak, misisnformation was spread by media and health authorities. Click the link below and learn more from a letter released by the Australasian Professional Society on Alcohol and other Drugs³⁵.

Miscommunication about the causes of the US outbreak of lung diseases in vapers by public health authorities and the media

Outbreak named EVALI

E-cigarette or Vaping Product Use-Associated Lung Injury

People have been vaping in the USA for over 10 years without lung injury outbreaks³⁶. In the summer of 2019, a sudden outbreak of severe lung injuries occurred in North America, mainly the USA. Over 2800 cases were identified, causing 68 deaths³⁰.

Absence of infection³⁷

Hx of recent vaping

Age of patients (median 23):
15% under 18 years old
37% 18-24 years old
24% 25-34 years old
24% 35+ years old³⁰

^{Patients presented with a nonproductive cough, shortness of breath, tachycardia, and fever³⁸.}

Investigations

Labs and interviews

58 American EVALI patients were interviewed; 91% reported using illegal THC cartridges³⁹. 51 lung fluid samples of lung injured patients tested positive for fat based substances used in THC cartridges: 48 vitamin E acetate, 1 coconut oil, 1 limonene (a “terpene” found in cannabis)⁴⁰.

EVALI quickly declined

Law enforcement responded

44 websites were seized that were advertising the sale of illegal THC cartridges⁴¹. Millions of dollars worth of THC concentrates and cartridges were seized from illegal operations in Wisconsin and Minnesota^{42, 43}.

Commercial nicotine eliquid

Federal regulations

Ingredients in nicotine eliquids have been restricted by Canadian government regulations since May 2018⁴⁴. Lipophilic ingredients are not allowed in commercial nicotine eliquids⁴⁴. Nicotine eliquid is an aqueous solution and lipids won’t dissolve in it⁴⁵.

THC cartridges in Canada

Government controlled

THC cartridges were approved for sale in Canada October 19, 2019 during the lung injury outbreak⁴⁶. Of the 19 Canadian patients with EVALI, 11 reported they only vaped nicotine (many during a time when THC cartridges were illegal)⁴⁷. Neither toxicology screens nor lung fluid biopsies were performed to confirm patients’ self-reporting⁴⁷.

Experiment with mice

Vitamin E Acetate aerosols

In this experiment, two controls were used: air and standard eliquid base of propylene glycol/vegetable glycerine blend. Mice exposed to the vitamin E acetate aerosols presented with signs consistent with EVALI⁴⁸.

Wide-spread misinformation

Discouraged harm reduction

Public Health England, March 2020:

“The mistaken belief that e-cigarettes are more harmful than smoking increased rapidly among UK smokers following the US lung injury outbreak in autumn 2019.”⁴⁹

Listen to the experts

Quotes from those that have done the research

“The burden of proof

is on the regulatory agency to
demonstrate that the product is unreasonably dangerous for its intended use…electronic cigarette prohibition will do harm to hundreds of thousands
of vapers already using electronic cigarettes in place of tobacco ones – a clear violation of nonmaleficence.”

Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel

“Current state of knowledge

about chemistry of liquids and
aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable
exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces.”

Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.

“Even if there are longterm

vapers, this is not a problem, as long as they quit smoking. The problem is combusted tobacco, not nicotine. At the dosage used by vapers or users of nicotine gums or patches, nicotine is not toxic. Long term vaping is not a public health problem; not any more than long term use of nicotine gums.”

Dr Jean-François Etter

“None of the toxicological

testing conducted in E-cigs has shown that users or bystanders are exposed to harmful levels of toxins or carcinogens. E-cigs eliminate exposure to the smoke toxicants responsible for nearly all smoking-related diseases.”

A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti

“The burden of proof

is on the regulatory agency to demonstrate that the product is unreasonably dangerous for its intended use…electronic cigarette prohibition will do harm to hundreds of thousands of vapers already using electronic cigarettes in place of tobacco ones – a clear violation of nonmaleficence.”

Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel

“Even if there are longterm

vapers, this is not a problem, as long as they quit smoking. The problem is combusted tobacco, not nicotine. At the dosage used by vapers or users of nicotine gums or patches, nicotine is not toxic. Long term vaping is not a public health problem; not any more than long term use of nicotine gums.”

Dr Jean-François Etter

“Current state of knowledge

about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces.”

Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.

“None of the toxicological

testing conducted in E-cigs has shown that users or bystanders are exposed to harmful levels of toxins or carcinogens. E-cigs eliminate exposure to the smoke toxicants responsible for nearly all smoking-related diseases.”

A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti

Facilitate informed decision making

Your patients’ lives depend on it

In the next section we look at the current false narratives about nicotine vaping and offer evidence to help you make informed decisions.

Next section: tobacco harm reduction

28. Sellers, D., McGraw, S., & McKinlay, J. (1994). Does the promotion and distribution of condoms increase teen sexual activity? Evidence from an HIV prevention program for Latino youth.

29. Institute of Economic Affairs. (2013). Free market solutions in health: The case of nicotine.

30. Centers for Disease Control and prevention. (2020). Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Updated February 25, 2020.

31. FDA. (2019). Vaping Illness Update: FDA warns public to stop using tetrahydrocannabinol (THC)-containing vaping products and any vaping products obtained off the street.

32. Utah Department of Health. (2019). Vaping-related lung injury, Utah, 2019: Investigation to date updated September 30, 2019.

33. Duffy, B.; Li, L.; Lu, S.; Durocher, L.; Dittmar, M.; Delaney-Baldwin, E.; Panawennage, D.; LeMaster, D.; Navarette, K.; Spink, D. (2019). Analysis of cannabinoid-containing fluids in illicit vaping cartridges recovered from pulmonary injury patients: Identification of vitamin E acetate as a major diluent.

34. Blount, B., Karwowski, M., Shields, P., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., Braselton, M., Brosius, C., Caron, K., Chambers, D., Corstvet, J., Cowan, E., et al., (2019). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI.

35. Australasian Professional Society on Alcohol and other Drugs. (2020). Miscommunication about the causes of the US outbreak of lung diseases in vapers by public health authorities and the media.

36. Public Health England. (2019). Vaping and lung disease in the US: PHE’s advice.

37. M. Perrine CG, Pickens CM, Boehmer TK, et al. Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:860–864.

38. J. Schier JG, Meiman JG, Layden J, et al. Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance. September 6, 2019 MMWR Morb Mortal Wkly Rep 2019;68:787–790

39. A. Taylor J, Wiens T, Peterson J, et al. Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement — Minnesota, 2018 and 2019. MMWR Morb Mortal Wkly Rep 2019;68:1096-1100.

40. B. Blount, B.C., Karwowski, M.P., Shields, P.G. et al. (2020). Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI.

41. C. US Food and Drug Administration. (2019). FDA, DEA seize 44 websites advertising sale of elicit THC cartridges to US consumers as part of Operation Vapor Lock.

42. D. ABC News. (2019). Sheriff details charges against brothers accused of running THC vape ring.

43. E. ABC News. (2019). Minnesota police seize over 75,000 THC vaping cartridges in record bust.

44. Government of Canada. (2018). Tobacco and Vaping Products Act.

45. F. Campagna, D., Amaradio, M.D., Sands, M., & Polosa, R. (2016). Respiratory infections and pneumonia: potential benefits of switching from smoking to vaping.

46. Government of Canada. (2019). Backgrounder: Final regulations on new cannabis products.

47. H. Government of Canada. (2019). Vaping-associated lung illness.

48. K. Bhat, T.A., Kalathil, S.G., Bogner, P.N., Blount, B.C., Goniewicz, M. L., & Thanavala, Y.M. (2020). An animal model of inhaled vitamin E acetate and EVALI-like lung injury.

49. L. Public Health England. (2020.) False fears preventing smokers from using e-cigarettes to quit.

Bioethics

by Kellie Ann Forbes | Feb ,Mon, 2020 | education, health professionals

Bioethics

Patients are a vulnerable population⁷⁹.

They trust health professionals with their health, well being and their lives.

They deserve to know all their options.

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Advocate for utilization of harm reduction

From first year of post-secondary education, health professionals are trained to trust “credible sources” such as health-related nonprofits, health authorities, regulatory bodies and internal information sources in the work place. Health professionals trust that the information that comes from credible sources are unbiased, accurate, and ethical⁷⁹.

However, in reference to the Syphilis Study at Tuskegee, health professionals are required to think critically and challenge unethical practices⁸⁰. This study, from 1932 to 1972, recorded the untreated effects of syphilis in 399 males against a control of 201 uninfected men. Subjects were poor and illiterate. They were not informed that they had syphilis, nor were they offered penicillin when it was found to be an effective treatment in 1945. In 1969 the Centers for Disease Control backed by the American Medical Association and the National Medical Association refused to inform the subjects of their infection nor offer treatment despite concerns voiced by citizens. Public outcry ended the study in 1972⁸⁰. Over 40 years, multiple doctors, nurses and other health professionals violated informed decision making and promoted harm.

Health professionals have a responsibility to resist blindly following authority, review the evidence and advocate for harm reduction to promote improved health outcomes⁷⁹.

Tobacco harm reduction

Compassionate and just approach

Health professionals’ primary bioethic is nonmaleficence; to do no harm. Miscommunication about tobacco harm reduction has compromised health professionals’ ability to promote autonomy in their smoking patients, specifically facilitating informed decision making⁸¹. Ensure beneficence by reviewing the credible evidence.

Basic vaping information

Misinformation

Supports continued profits

Public Health England estimates vaping helps at least 18,000 and as high as 57,000 smokers quit each year in the UK⁸². Not only have pharmaceutical smoking cessation prescriptions dropped more than 50% since vaping has been introduced but current vapers⁸³, and subsequently former smokers, are reporting a decreasing need for their medications for managing their smoking-related diseases⁸⁴.

Youth vaping epidemic

What about youth smoking?

Why are all the credible sources omitting significant data such as youth smoking rates are plummetting^85,86; vaping is a fraction the harm of smoking⁸⁷; nicotine is less addictive than cigarette smoke⁸⁴; and smokers are quitting using tobacco harm reduction⁸⁸? The hysteria over youth experimenting with vaping disregards the reduction in youth smoking uptake. One must look at the potential reduction in harm if youth are choosing to experiment with vaping instead of smoking due to the significant reduction in health destroying toxins and reduction in addiction potential⁸⁹.

Long term effects

We know the LT effects of smoking

Unlike with cigarettes, vaping has been developed in an age when science has studied and catalogued thousands of substances and how they effect human health⁹⁰. Eliquid and vapour have been thoroughly analyzed and the results consistently indicate that vaping is a very small fraction of the harm compared to smoking⁸⁷.

Bad science

False claims

Omitting significant data is coupled with false claims such as youth smoking rates are inclining⁹¹ and vaping causes heart attacks⁹². These questionable researchers have the audience of the most powerful tobacco control bureaucrats in Canada⁹³. It’s time the health community review the evidence and advocate for the effective utilization of vaping before these bureaucrats enact oppressive regulations which will destroy the industry that supplies Canadians with tobacco harm reduction⁹⁴.

Media

Click bait headlines

Mainstream media has been instrumental at spreading false narratives. Is the free press particularly Canada’s publicly funded CBC not responsible to report the facts so Canadians can make informed decisions on issues of public health⁹⁵? One must consider that media is significantly funded by the pharmaceutical industry⁹⁶.

Credible sources

Are they trustworthy?

Health-related nonprofits⁹⁷, health authorities, regulatory bodies and universal health care agencies have close and often financial relationships with industry that profit from ill-health such as the pharmaceutical, medical supply, and medical equipment industries. These industries fund a large portion of our scientific research, medical schools⁹⁸, tobacco control conferences⁹⁹ and so on.

Health-related nonprofits

Revenue contingent on disease

Health professionals trust these agencies as credible sources of information because they have been trained to. It’s time to start questioning sources of information that revenue comes as a result of diseases. These agencies do not have answer to the bioethics of professional codes of ethics that guide the practice of health professionals.

Regulatory bodies

On the bandwagon

Professional regulatory bodies make professional conduct and responsibilities for their members. But do these ethics apply to the agencies as well? The Canadian Nurses Association has been a leader in harm reduction for illicit drug users since 2007¹⁰⁰.

Front line workers

The final fail safe

When the system fails, it’s the front line workers that must advocate for appropriate application of science to improve population health outcomes. These health professionals witness the suffering caused from smoking everyday. Will they review the evidence, challenge the opinion of majority and do the right thing?

79. Canadian Nurses Association. (2017). Code of ethics for registered nurses.

80. Centers for Disease Control and Prevention. (2015). U.S. Public Health Service Syphilis Study at Tuskegee.

81. Huang. J. et al. (2019). Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US National surveys from 2012 to 2017.

82. Public Health England. (2018). Key questions and findings from our e-cigarette evidence update

83. NHS Digital. (2019). Statistics on smoking, England – 2019.

84. Farsalinos, K. E., Romagna, G., Tsiapras, D., Kyrzopoulos, S., & Voudris, V. (2014). Characteristics, perceived side effects and benefits of electronic cigarette use: A worldwide survey of more than 19,000 consumers.

85. Government of Canada. (2015). Canadian Student Tobacco, Alcohol and Drugs Survey.

86. Government of Canada. (2019). Canadian Student Tobacco, Alcohol and Drugs Survey.

87. Abrams, D. B., Glasser, A. M., Pearson, J. L., Villanti, A. C., Collins, L. K., & Niaura, R. S. (2018). Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives. Annual Review of Public Health.

88. Farsalinos KE, Barbouni A. Association between electronic cigarette use and smoking cessation in the European Union in 2017: analysis of a representative sample of 13 057 Europeans from 28 countries.

89. A Consensus Study Report of the National Academies of Sciences, Engineering and Medicine. (2018). Public Health Consequences of E-cigarettes. Page 33.

90. Canadian Centre for Health and Safety. (2020). Registry of Toxic Effects of Chemical Substances (RTECS).

91. Hammond, D. et al. (2019). Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys.

92. Journal of the American Heart Association. (2020). Retraction to: Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health.

93. University of Ottawa Heart Institute. (2020). Top Smoking Cessation Authorities Gather at Ottawa Conference – Day 1. Retreived Feb. 19, 2020 from https://www.ottawaheart.ca/media-release/top-smoking-cessation-authorities-gather-ottawa-conference-day-1.

94. Public Health Agency of Canada (2020). Statement from the Council of Chief Medical Officers of Health on Nicotine Vaping in Canada.\

95. Canadian Broadcast Corporation. (2017). Code of Conduct: Working together: Our values, ethical principles and expected behaviour. Retrieved Feb. 19, 2020 from https://site-cbc.radio-canada.ca/documents/values-ethics/values-ethics/code-conduct-en.pdf

96. Kantar US Insights. (2017). Retrieved Feb 19, 2020 from https://us.kantar.com/business/health/2017/drug-advertising-booms/

97. Women and Health Protection (WHP). (2005). Marching to Different Drummers: Health Advocacy Groups in Canada and Funding from the Pharmaceutical Industry. Retrieved Faeb. 19, 2020 from http://www.whp-apsf.ca/pdf/corpFunding.pdf

98. Canadian Medical Association Journal. (2013). Pharma influence widespread at medical schools: study. Retrieved Fab. 19, 2020 from https://www.cmaj.ca/content/185/13/1121

99. 12th Annual Ottawa Conference State of the Art Clinical Approaches to Smoking Cessation. (2020). Conference program. Page 17. Retrieved Feb. 19, 2020 from https://ottawamodel.ottawaheart.ca/sites/default/files/2020_program_-_web.pdf

100. Canadian Nurses Association. (2020). Harm reduction. Retrieved Feb. 19, 2020 from https://www.cna-aiic.ca/en/policy-advocacy/harm-reduction.

Health professionals

by Kellie Ann Forbes | Feb ,Sun, 2020 | education, health professionals

Health professionals

Smoking is the most preventable cause of morbidity and mortality in Canada.¹

We invite you to make informed decisions about tobacco harm reduction.

"

Optimal patient care

If you are a health professional, you have chosen a caring profession that entrusts you to advise your patients with accurate information to improve their health outcomes.² You are trusted by the public, authorities and your colleagues to communicate relevant information and you rely on your sources to provide you with current, unbiased and credible evidence³.

Undoubtedly, you care for and treat patients that are hopelessly addicted to cigarette smoke. As much as you communicate the devastating health effects of smoking and witness the patients’ resulting decline, they are powerless and you are frustrated that they can’t quit⁴.

If cessation of high risk behaviours (in this case cigarette smoking) is not happening, the next best strategy is harm reduction³. Would you want to know if your current best educated advice for smokers is actually causing great harm? We invite to look at the credible evidence to ensure best practice.

Section 1

Smoking

Before you can understand the relevance of harm reduction you first must understand what is causing harm⁵. Learn about what goes into cigarettes, the constituents of the smoke, and the social cost.

Section 2

The current context

Since summer of 2019, the media, health-related nonprofits, regulatory agencies and health authorities have been repeating the same congruent narratives about vaping without debate nor deviation. The current discourse about harm reduction omits significant data⁶.

Section 3

Tobacco harm reduction

Vaping has been thoroughly studied in labs and in real life context. A search on a medical data base resulted in over 22,000 published articles. We take you through the 10 most common myths about vaping and link you to more evidence.

Section 4

Bioethics

In this section we challenge health professionals to apply bioethics to the current context. Health professionals care about their patients’ outcomes and are required to advocate for change when current practice is causing harm³.

First section: Smoking

1. Health Canada. (2014). Health concerns: Notice of proposed order to amend the schedule to the Tobacco Act.

2. Canadian Nurses Association. (2017). Code of ethics for registered nurses.

3. Canadian Nurses Association. (2018). Harm reduction and substance use: Joint position statement.

4. Centers for Disease Control and Prevention. (2010). A report of the surgeon general: How tobacco smoke causes disease: What it means to you.

5. Canadian Nurses Association. (2017). Harm reduction and illicit substance use: Implications for nursing.

6. Australasian Professional Society on Alcohol and other Drugs. (2020). Miscommunication about the causes of the US outbreak of lung diseases in vapers by public health authorities and the media.

Smoking

by Kellie Ann Forbes | Feb ,Thu, 2020 | health professionals

Smoking

Every year in Canada, smoking causes 18% of all deaths and costs the taxpayers $16 billion⁷.
Over one million Canadians suffer with smoking-related diseases^7,8.

Smoking morbidity and mortality is 100% preventable⁹.

"

Diagnose the problem

Cigarette smoke addiction

Cigarettes became mainstream in the early 20th century due to automation which made them economically viable to produce¹⁰. Over decades, tobacco company scientists experimented with chemicals to produce the most addictive product in the world¹⁰.

Currently, up to 600 ingredients are added to tobacco cigarettes to cause physiological outcomes and enhance the delivery and effects of nicotine¹¹. Ammonium salts increase nicotine bioavailability; menthol acts as a local anaesthetic and cough suppressant¹². Eucalyptol and theobromine are bronchial dilators to increase the volume of smoke inhaled¹². Then, lactones reduce the body’s ability to metabolize nicotine; and acetaldehyde mimics monoamine oxidase inhibitors (anti-depressant effect)¹².

Cigarettes are more addictive than just nicotine on its own and the most harmful source of nicotine¹³. When smokers switched to tobacco harm reduction (THR), they reported improvements in chronic diseases¹⁴and general health ¹⁵.

Smoking vs. vaping chart

At-risk populations

Higher prevalence in vulnerable populations

Those with metal health disorders have double the smoking prevalence of the general population¹⁶. For instance, people with schizophrenia have up to 80% prevalence¹⁷. Cigarettes are the most harmful source of nicotine¹⁸.

While smoking prevalence has significantly declined in the last 50 years, people of lower socio-economic status prevalence has hardly changed¹⁹. Considering that a pack of cigarettes in Canada costs up to $20, this expense adversely effects their ability to afford healthy food for themselves and their children.

Learn from the experts in THR

Smoking rates

15% of Canadians smoke

About 4.6 million Canadians 15 years and older are addicted to cigarette smoke²⁰. It is the most common addiction in Canada²¹. Toxins in smoke include: carbon monoxide which displaces oxygen on RBC; hydrogen cyanide which paralyses lung cilia; free radicals which cause atherosclerosis²².

7000+ chemicals in smoke

Combustion is a problem

Burning chemical laden cigarettes cause new toxins to form²². Cigarette smoke contains hundreds of known disease causing agents and 69 carcinogens^{11, 22}. Smoking is responsible for 36% of respiratory diseases, 29% of cancers, 14% of cardiovascular diseases, 85% of lung cancer and 87% of COPD²³.

100% preventable costs

Death and taxes

Premature deaths caused from smoking leads to 599,390 potential years of life lost²⁴. Tax expenditures include $6.4 billion in direct health care costs and indirect costs includes $6.8 billion for long-term disability²⁴.

The needless suffering

The human element

The accumulative effects of the toxins deteriorates the smoker’s health²². This adversely effects their families such as when the main earner can no longer work and their children cannot afford a higher education²⁴.

Long term effects

The next generation

If we help grandparents stop smoking, they can enjoy active relationships with their grandchildren. After one year of quitting smoking, patients’ risk of heart attack reduces by 50%; after 10 years, risk of lung cancer is reduced to 50% and risk of coronary heart disease is the same as a never smoker²⁵.

Harm reduction for smokers

Medical autonomy

When patients are unable to cease risky behaviours, the next best intervention is harm reduction such as practising safe sex to avoid HIV²⁶. Health professionals are responsible to promote harm reduction²⁷.

Stay current in the evidence

What you don’t know can harm your patients

Let the scientific findings guide your practice.

Next section: the current context

7. The Conference Board of Canada. (2017). The costs of tobacco use in Canada, 2012.

8. Centres for Disease Control and Prevention. (2014). Fast facts: Diseases and death.

9. Health Canada. (2014). Health concerns: Notice of proposed order to amend the schedule to the Tobacco Act.

10. Institute of Economic Affairs. (2013). Free market solutions in health: The case of nicotine.

11. Rabinoff, M., Caskey, N., Rissling, A., & Park, C. (2007). Pharmacological and Chemical Effects of Cigarette Additives.

12. Europa. (2010). Public Health: Tobacco additives.

13. Laugesen, M. (2013). Nicotine and health.

14. Farsalinos, K. E., Romagna, G., Tsiapras, D., Kyrzopoulos, S., & Voudris, V. (2014). Characteristics, perceived side effects and benefits of electronic cigarette use: A worldwide survey of more than 19,000 consumers.

15. Polosa, R., Rodu, B., Caponnetto, P., Maglia, M., & Raciti, C. (2013). A fresh look at tobacco harm  reduction: the case for the electronic cigarette.

16. Mental Health and Smoking Partnership. (2017). Statement on Electronic Cigarettes

17. Royal College of Physicians. (2013). Smoking and mental health: A joint report by the Royal College of Physicians and the Royal College of Psychiatrists.

18. Nutt, D. J., Phillips, L. D., Balfour, D., Curran, H. V., Dockrell, M., Foulds, J., Fagerstrom, K., Letlape, K., Milton, A., Polosa, R., Ramsey, J., & Sweanor, D. (2014). Estimating the harms of nicotine-containing products using the MCDA approach.

19. Public Health England. (2015). E-cigarettes: an evidence update A report commissioned by Public Health England.

20. Reid, J., Hammond, D., Tariq, U., Burkhalter, R., Rynard, V.L., & Douglas, O. (2019). Tobacco Use in Canada: Patterns and Trends, 2019 Edition.

21. Public Health Agency Canada. (2014). Tobacco.

22. A Report of the Surgeon General. (2010). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General.

23. Dawkins, L. (2013). Why is it so hard to quit smoking?

24. Conference Board of Canada. (2017). The Costs of Tobacco Use in Canada, 2012.

25. Canadian Cancer Society. (2020). Amazing ways your body bounces back.

26. Canadian Nurses Association. (2017). Harm reduction & illicit substance use: Implications for nursing.

27. Canadian Nurses Association. (2018). Harm reduction and substance use: Joint position statement.

APSAD paper

by Kellie Ann Forbes | Jan ,Mon, 2020 | education, health professionals

Australasian Professional Society on Alcohol and other Drugs

A professional critique of how EVALI was handled

Miscommunication about the causes of the US outbreak of lung

download

Miscommunication about the causes of the US outbreak of lung

download

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Educate health professionals

by Kellie Ann Forbes | Jan ,Mon, 2020 | education, health professionals

Call to Action

Teach health professionals

about vaping-related lung injuries

CNA Harm Reduction

Jan. 2020, Australasian Professional Society on Alcohol and other Drugs releases:

“Miscommunication about the causes of the US outbreak of lung diseases in vapers by public health authorities and the media”.

EVERY health professional who reads this will have full comprehension on the truth about what is causing vaping related lung injuries, how the CDC has deceived the public about it and that they have been getting a false narrative.

This credible paper is a short read consisting of only 2 pages yet cites 32 references.

Source

Here is the paper, just print it off.

download

Now, write VAEPworld.com on the back.

All you have to do now is give it to the receptionist or practitioner at health professional offices.

Because vaping is a hot topic right now and this is a short, credible paper, it will probably get passed around the staff room. Since you wrote VAEPworld.com on the back, you have helped them learn more PLUS given them somewhere to send their patients for infomation on tobacco harm reduction! This means YOU have made all the difference in the world!

Suggestions for places to drop it off:

pharmacies
emergency rooms
hospital admissions
walk in clinics
dentist offices
community/public health clinics
doctor’s offices
mental health centers
harm reduction clinics
optomatrist offices
labs
physiotherapy offices
chiropracter offices
naturopathy offices