
Gov’t and MSA payments

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.
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.
The recent outbreak of vaping-related lung injuries were a result of illegal THC (cannabis) cartridges used in vaping devices30,31,32. Vitamin E acetate has been identified as the primary causative agent33,34.
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.
Outbreak named EVALI
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.
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
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
Commercial nicotine eliquid
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
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
Wide-spread misinformation
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
Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel
Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.
Dr Jean-François Etter
A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti
Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel
Dr Jean-François Etter
Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.
A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti
In the next section we look at the current false narratives about nicotine vaping and offer evidence to help you make informed decisions.
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.
Patients are a vulnerable population79.
They trust health professionals with their health, well being and their lives.
They deserve to know all their options.
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.
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.
Misinformation
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
Long term effects
Bad science
Media
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
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
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
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
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.
Smoking is the most preventable cause of morbidity and mortality in Canada.1
We invite you to make informed decisions about tobacco harm reduction.
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
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
Section 3
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
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.
Every year in Canada, smoking causes 18% of all deaths and costs the taxpayers $16 billion7.
Over one million Canadians suffer with smoking-related diseases7,8.
Smoking morbidity and mortality is 100% preventable9.
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 diseases14 and general health 15.
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.
Smoking rates
7000+ chemicals in smoke
Burning chemical laden cigarettes cause new toxins to form22. Cigarette smoke contains hundreds of known disease causing agents and 69 carcinogens11, 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
The needless suffering
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
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.
Let the scientific findings guide your practice.
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.
Updated 01FEB2020
“Vaping nicotine can alter teen brain development.”
– Health Canada
“Vaping can cause lung damage.”
– Health Canada
Harm
reduction
“Every 10 minutes, two Canadian teenagers start smoking cigarettes; one of them will lose her life because of it.” -Health Canada (22)
The current
narrative
Making a
smoker
What about
vaping?
Harm
reduction
Making a
smoker
What about
vaping?
Youth and
vaping
The current
narrative
Harm
reduction