15 December 2019
E-cigarettes are on the market ostensibly to help smokers quit tobacco, but Quebec teens are getting addicted at an alarming rate.
Nicholas Chadi treats a new generation of nicotine addicts: children hooked on vaping.
“One pre-filled (vaping) cartridge — the type kids use most of the time — contains nicotine equivalent of one to two packs of cigarettes,” said Chadi, a pediatrician and addiction specialist at Ste-Justine Hospital.
“So one little cartridge that’s the size of your thumbnail can contain as much nicotine as 20 to 40 cigarettes, and some (teenagers) are going through one or two or even three or four of those pods a day.”
Nicotine is the substance that makes smoking so addictive. Ironically, teens are getting addicted to it via a tool ostensibly on the market to help smokers quit tobacco.
Though largely blamed on counterfeit products, a recent outbreak of vaping-linked lung injuries has led health authorities to advise caution about all types of e-cigarettes until the investigation is completed.
Experts say no one knows vaping’s long-term health effects on adults. But they’re clear about one thing: Nicotine harms teenage brains.
Lured by slick advertising, tens of thousands of Canadian youth are addicted to it, said Chadi, lead scientist on a Canadian study tracking acute vaping-related health problems among youth.
Vaping products are readily available in dépanneurs. And it’s easy to sneak a puff, even in school, as vape pens are small, easily concealed and the odour dissipates quickly.
There has never been such a rapid uptake in an addictive substance among teens, Chadi said. And Quebec youth are among the most addicted in Canada.
“It’s very, very addictive because (e-cigarettes) come in pleasant flavours,” many of them fruity or candy-like, Chadi said.
“And it’s not like smoking cigarettes where you get the bad breath and the bad smell. You just get the same amount of nicotine or even more and you also get the pleasurable experience” due to the taste.
Smoking has gone out of fashion among youth — eight per cent of Quebec teens light up today, less than one-quarter the number who did so 20 years ago.
Chadi sees vaping’s short-term impact. Some of his young patients report coughing more, having trouble breathing, and not being able to run as fast as they used to. Side-effects can include intense head rushes and nausea.
“Longer-term, we know nicotine can have an impact on how the (young) brain changes and develops,” Chadi added. “Nicotine can reduce your capacity to focus, learn and memorize, the same way that exposure to cannabis and alcohol can when you’re a young person.”
Two studies issued in November show Quebec was initially a leader at keeping kids away from vaping, but that has changed.
Usage among teens did not rise as quickly between 2013 and 2017 in Quebec and other provinces that were the first to ban sales to minors, according to a Memorial University study. During that period, Quebec youth were also more likely to think e-cigarettes could be harmful to health — and to say they found it difficult to access vaping products.
Fast-forward to today, and Quebec has the highest youth vaping rates of four provinces recently studied.
Thirty-two per cent of Quebec students in Grades 9 to 11 reported having vaped in the past 30 days during the 2018-19 school year, up from 15 per cent two years earlier, according to a cross-Canada study co-ordinated by the University of Waterloo.
“We didn’t learn from the past,” said Flory Doucas, co-director of the Quebec Coalition for Tobacco Control.
Cigarettes have killed untold numbers of Canadians. This year, the Quebec Court of Appeal upheld a judgment ordering three tobacco companies — Imperial Tobacco, JTI-Macdonald, and Rothman, Benson & Hedges — to pay smokers billions in damages after failing to inform them of health risks and using marketing strategies that exposed consumers to the risk of addiction or fatal disease.
“The lessons learned from the fight against tobacco weren’t used and Health Canada had kind of a rainbow and unicorns approach to vaping” when it started regulating the new generation of nicotine products in 2018, Doucas said.
Though e-cigarettes with nicotine were technically banned by Health Canada until then, they were widely available in underground shops and online.
Anxious to shield youth, Quebec filled the regulatory void in 2015 by imposing provincial rules to govern their sale, marketing and use. The directives were similar to those applied to cigarettes: no selling to minors, no advertising where young people could see it, no vaping in places where smoking was already banned. Online sales were also prohibited.
Then, in 2018, Ottawa imposed federal rules. Sales to minors were banned across Canada, as were misleading ads and marketing that target children. But online sales were allowed in provinces that had not already forbidden them.
And in some places, vaping companies were allowed to advertise in places where tobacco ads were outlawed — inside and outside corner stores and gas stations. Those rules did not apply to Quebec. But in other parts of Canada, companies advertised heavily, using colourful ads touting fruit-flavoured vaping that critics say targeted young people.
The federal rules also allowed vaping ads on social media, where Quebec had a hard time enforcing its ad ban, Doucas said. Ads on Instagram and other platforms often featured hip, happy young people in clouds of vapour.
Ottawa had hoped opening the door to vaping would encourage smokers to quit, giving them the nicotine they’re addicted to without the carcinogenic tobacco smoke.
“That took the premise that the industry would only target current smokers and not seek to increase market share,” Doucas said. But deep-pocketed vaping companies, including those with links to cigarette-makers, used the “very permissive advertising rules” to reel in new users to vaping the way Big Tobacco did to cigarettes, she added.
As in other provinces, Quebec allowed vaping products to be sold in stores frequented by youth, including dépanneurs and gas stations.
Then there are the flavours. Under federal rules that apply in Quebec, vaping products can be flavoured, though names cannot refer to desserts or candy. For example, “strawberry cheesecake” is a no-no, but “strawberry” is OK.
That’s in contrast to cigarettes, where no flavours are permitted.
“They were banned (in cigarettes) for a reason — we knew that using flavours was one way the industry used to make their products very attractive and very palatable to new users, including children,” Doucas said.
Sixty-nine per cent of youth aged 15 to 19 reported using a fruit flavour the last time they used an e-cigarette, according to Health Canada statistics.
Flavours tend to trivialize products, Doucas said. “It’s pretty hard to take something seriously or to think it’s harmful when it tastes like mango.”
Doucas’s organization, along with the Canadian Medical Association and the Canadian Cancer Society, are urging Ottawa to act.
They want advertising restrictions similar to those that apply to tobacco, including no ads on social media, as well as a ban on most if not all flavoured products.
They also want maximum nicotine levels lowered from the current 66 milligrams per millilitre to the European limit — 20 mg/ml — because higher concentrations are thought to be more addicting.
Health authorities have scrambled to get a grip on recent vaping illnesses.
In the U.S, as of Dec. 3, 48 people had died of vaping-related lung injuries and 2,291 people had been hospitalized, often in intensive care units, with symptoms such as cough, shortness of breath, nausea and abdominal pain. Most had used products that contained THC, the compound in cannabis that produces the high.
After an intense investigation, the U.S. Centres for Disease Control says it has found a “very strong culprit:” vitamin E acetate, often used as a thickening agent in THC products available on the black market. In Canada, a ban on cannabis vaping products is set to lift in mid-December, though they will still be prohibited in Quebec.
But the CDC says there may be “other chemicals of concern. … Many different substances and product sources are still under investigation, and it may be that there is more than one cause of this outbreak. The only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products.”
Adding to the mystery, Quebecers suffering from what the province’s Health Ministry calls “pulmonary diseases associated with vaping” had not been using THC-laced products, health officials reported in a Dec. 3 update. There are four confirmed cases and another probable one in Quebec. All had used legal nicotine products.
And in Ontario, doctors in November reported what they call a new type of vaping-related lung injury distinct from those seen elsewhere. A 17-year-old boy ended up on life-support with an injury similar to “popcorn lung,” seen in workers exposed to a chemical flavouring used in microwave popcorn. He was a regular user of flavoured nicotine and THC.
Across North America, governments are mulling options.
Several U.S. states banned flavoured e-cigarettes, an idea the Trump administration also floated. Some American jurisdictions are also suing Juul, maker of sleek, high-nicotine vaping devices and partly owned by cigarette maker Philip Morris. Juul, also active in Canada, stands accused of engaging in deceptive marketing that targets minors.
In October, chief medical officers of every Canadian province and territory jointly called for more restrictions on vaping and the introduction of plain packaging to make products less appealing to youth.
They said they are “concerned that a new generation of youth addicted to nicotine will lead to a resurgence in smoking.”
Stopping short of calling on adults to quit vaping, the public health officers noted “researchers are still gathering data on (vaping’s) potential effectiveness as a means of helping smokers quit smoking” and they urged Canadians using tobacco to “seek proven cessation therapies such as gums, patches or lozenges.”
Health Canada has been considering changes to federal rules since February. No timeline has been set.
In December, Nova Scotia became the first province to announce a flavour ban; it will take effect in April.
Quebec plans to crack down next year.
Health Minister Danielle McCann says her department will look at restricting flavours, reducing permitted nicotine levels and tightening rules that allow vaping devices to be sold in dépanneurs and gas stations. Reports suggest the province may restrict sales to pharmacies, by prescription.
A vaping lobby group whose members include Imperial Tobacco and Juul denounced the ideas Quebec is considering.
Restricting flavours, limiting sales to pharmacies and capping nicotine concentrations “would have the effect of limiting access to and desirability of the product, which would drastically undermine the switching rates of smokers towards these less harmful alternatives,” says the Vaping Industry Trade Association.
Frosted glass — a legal requirement in Quebec to keep youth from seeing inside — blocks passersby who want to take a peek into La Vapote, a vape shop on Bélanger St. in Rosemont. Inside, John Xydous, the store’s co-owner, stands behind the counter as a potential customer enters and asks him for a vaping primer.
“I start by explaining how vaping works,” Xydous said, gesturing toward a display case containing dozens of vape pens — devices that resemble elongated USB drives, some staid brown, others in bright colours.
Behind Xydous, shelves are lined with small, colourful plastic bottles of so-called vape juice or e-liquid in 50 flavours, most containing nicotine. Some replicate the taste of tobacco but most come in other pleasant-sounding flavours, including caramel-pecan, cereal-with-strawberry, vanilla-custard. They’re in a variety of nicotine dosages, from 3 mg/ml to 50 mg/ml.
All vape pens feature a battery, a heating element and cotton that absorbs the liquid, Xydous explains. The device heats the liquid to form an aerosol that’s inhaled. There’s no tobacco, burning or smoke.
Xydous, Quebec director of the Canadian Vaping Association, a trade group that does not include tobacco companies, said he helps customers determine how much nicotine they’ll need, based on their smoking habit.
Corner stores and gas stations tend to sell devices that rely on disposable pods pre-filled with vape juice. Such stores typically offer one or two relatively high doses of nicotine — 30 mg/ml and 50 mg/ml, for example.
In contrast, specialized vape shops largely sell devices that use refillable pods. Users pour vape juice into the pods, which are in turn inserted into vape pens.
Xydous said most customers are long-time smokers looking to quit — and all are adults. A sandwich board outside the store warns that customers may be carded to ensure they are not under 18, the legal vaping age in Quebec.
Recent health concerns have caused a steep drop in sales in Canadian vape shops, many of them mom-and-pop operations, said Xydous, who also co-owns vape stores in Châteauguay and Joliette. “People who in the past would have believed it’s a safer alternative are starting to believe it’s safer to smoke.”
He points to a 2016 report by the Royal College of Physicians in the United Kingdom that concluded e-cigarettes are 95-per-cent less hazardous to health than tobacco. And he notes Health Canada’s website says vaping is “less harmful than smoking” and completely replacing cigarettes with vaping will reduce a smoker’s exposure to harmful chemicals.
Some suggestions being floated to stem youth vaping — banning all but tobacco-flavoured juices, for example — are misguided, Xydous said.
“Some people trying to quit smoking want to disassociate with tobacco,” he said. “By using flavours and making it taste good, it helps them to choose the healthier option.” A flavour ban would encourage use of questionable products from the black market, according to Xydous.
Banning flavours would kill vape shops and effectively “hand over the industry to Big Tobacco which gladly would only sell tobacco-flavoured vaping products as it helps promote their most profitable product: cigarettes,” Xydous said.
He hopes vaping products will be banned from regular stores and instead limited to specialized, age-restricted stores staffed by knowledgeable vendors who can help smokers find the right vaping dosage to quit tobacco, he said.
In May, a judge struck down Quebec rules banning demonstrations of vaping products inside shops, as well as the province’s prohibition of vaping advertising to smokers seeking to kick their habit. Quebec is appealing the decision.
Joseph Erban has been helping people quit tobacco for 15 years, running free group smoking-cessation clinics at the Jewish General Hospital and visiting schools to talk about smoking and vaping.
Many young people he meets falsely believe vaping is healthy and non-addictive, said Erban, a smoking-cessation counsellor. “With flavours like mango, these kids think they are just consuming a harmless product and before you know it they become addicted.”
Among adults, multiple addictions are increasingly common, he said. “It’s not uncommon nowadays to see people at our clinic who vape cannabis, vape nicotine-containing products and also smoke cigarettes,” Erban said.
Among those he is currently helping is Jean, a 53-year-old project manager who didn’t want his last name published because of the stigma of his double dependence. He started vaping to kick the cigarette habit he picked up when he was 13.
Jean smokes a few cigarettes daily — morning and evening — and takes vaping breaks at work. He’s trying to quit both.
“I started vaping because it’s better for my health — there are fewer chemicals,” he said. “But we really don’t know what’s in the vaping liquids. They could cause more problems down the road.”
Does Erban suggest vaping to adults trying to quit tobacco?
“No, it’s highly addictive. Why would you recommend one addiction for another?” he said. Instead, he often recommends treatments that include nicotine patches, gum, inhalers and mouth sprays.
“We’re into total harm reduction,” Erban said. “We want people to lead a healthy lifestyle and that entails breathing air and not inhaling any other substance than that.”
However, some doctors say vaping must remain an option for smokers trying to kick their riskier, potentially fatal tobacco habit.
“Although not smoking or vaping is the safest option, many smokers need to vape in order to quit smoking,” cardiologist Martin Juneau, director of prevention at the Montreal Heart Institute, wrote on his blog in September.
“If they heed calls to stop vaping, these people who are highly addicted to nicotine might start smoking again. This will cause a lot more damage than vaping.”
He pointed to a study published in February that found e-cigarettes were almost twice as effective as nicotine patches, gum, lozenges and nasal spray.
Some smokers are unable to quit with other cessation tools, leaving them at risk of premature death, Juneau noted in a follow-up blog post.
For them, vaping can “significantly reduce their exposure to the many toxic substances of cigarette smoke, with immediate positive repercussions on their (cardiovascular) health. … Instead of trying to demonize e-cigarettes, we should rather see these devices as a very interesting technological innovation that adds a new dimension to the fight against tobacco.”
Michael Pollak, an oncologist and director of the McGill University-Jewish General Hospital Cancer Prevention Centre, says vaping should be sold by prescription and only to those trying to quit smoking.
“I would expect (vaping) to be less carcinogenic than tobacco. But the flavours, after they have been heated, are there carcinogens in there that might cause trouble five or 10 years later?
“The answer is we don’t know because we haven’t been using it long enough,” Pollak said. “A flavour that might be safe if ingested in your mouth, who knows what it does if it gets heated and complicated biochemistry happens and it makes new compounds and you inhale that to your lungs.”
Burning tobacco releases more than 7,000 chemicals, including more than 70 that are cancer-causing, Health Canada says.
The main liquids in vaping products — vegetable glycerine and propylene glycol — are considered safe for use in cosmetics and sweeteners but the federal agency notes the long-term safety of inhaling the substances is unknown.
As for flavouring chemicals, while safe to eat, “these ingredients have not been tested to see if they are safe to breathe in.”
Vaping is too new a phenomenon to meaningfully assess its health effects over a prolonged period, Pollak said.
“When you’re talking about safety to an exposure to anything, you have to deal with the expected time course. (Even) smoking tobacco is safe for the first six months.”
It may take years to understand the hazards of vaping, Pollak said.
“We know that maybe a quarter to a third of the population is susceptible to getting addicted to nicotine so we know that once (teens) start vaping many of them will never be able to get off it.”