68 Albertan Physicians: Vapes are not smoking cessation devices

June 21, 2020

Premier Jason Kenny, Minister of Health, Tyler Shandro

And to all: Members of the Legislative Assembly of Alberta c/o Office of the Premier

307 Legislature Building, Edmonton

c/o Email: Premier@gov.ab.ca

Ms. Rachel Notley, Leader of the Opposition

c/o Email: Edmonton.Strathcona@assembly.ab.ca

MLA Calgary Klein, Jeromy Nixon, Calgary.Klein@assembly.ab.ca

Cc. Dr. Deena Hinshaw, Chief Medical Officer of Health for Alberta

       Deena.Hinshaw@gov.ab.ca 

Dear Premier Kenney, Minister Shandro, Ms. Notley, Mr. Nixon and all other Members of the Legislative Assembly of Alberta,

Thank you very much for recognizing that vaping is a serious problem for Alberta children and youth, for requiring age verification and restricting advertising.  We were dismayed to learn that the Government did not take the opportunity in Second Reading to amend Bill 19 to make vaping less dangerous.

We write to correct possible misapprehensions.  You have been told that vaping decreases the risks of smoking, but that argument is not sound. 

1. Adults: vaping products as smoking quitting devices

There is no convincing evidence that vaping reduces smoking in adults. 

First, no vaping product has been approved as a smoking cessation aid because there is lack of evidence for their long-term effect.  Second, it is odd to think that vaping is a good tool to reduce nicotine dependence because it is a consumer product that has not been demonstrated to be, or approved as, a smoking cessation device.  Vape manufacturers are not health promoters.  Third, a systematic review published in The Lancet, Respiratory Medicine, reported that the odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes (odds ratio [OR] 0·72, 95% CI 0·57–0·91).  The review concluded, “As currently being used, e-cigarettes are associated with significantly less quitting among smokers.”  Fourth, reviewing all relevant studies then published, for the US Annual Review of Public Health, tobacco researchers, Stanton A. Glantz and David W. Bareham summarized the data in this way:

These results suggest that e-cigarettes are contributing to the tobacco epidemic by attracting smokers who are interested in quitting but reducing the likelihood of those smokers to quit successfully.

In other words, vaping does not lead to quitting smoking.  Vaping does not reduce nicotine addiction. 

Indeed an engineer who worked with the JUUL development team, is quoted by the New York Times as saying, “We don’t think a lot about addiction here because we’re not trying to design a cessation product at all.”

• Children and Youth: vaping products as smoking quitting devices

Vaping increases the likelihood that children and youth will smoke.

Children are not born vaping but the vaping industry encourages them to start.  Children and youth are directly targeted by tobacco and vaping industry to encourage them to vape.  As a review article in Pediatrics noted, “The ubiquitous marketing, promotion, and sales of e-cigarettes have been effective, with dramatic increases in youth e-cigarette use.^” 

Once children and youth become addicted to nicotine through vaping, then they often switch to a less-expensive nicotine delivery device, combustible cigarettes (i.e. they start smoking).  A young person who would otherwise be at low risk of starting to smoke cigarettes, has an 8.5 times greater the odds of becoming a smoker if he or she starts to vape.  Moreover, a 2018 National Academy of Sciences review found moderate evidence that vaping “increases the frequency and intensity” of subsequent cigarette smoking.

• Harms of vaping

The vaping industry would like you to believe that vaping is not as harmful as smoking.  We do not know the long-term effects of vaping because the practice is relatively new, especially the nicotine salt preparation patented by JUUL in 2015.  Some of the known harms of vaping nicotine-based products have been widely reported.  Nicotine has long been known to have serious adverse effects to virtually every organ system, but can result in specific harm to lungs when inhaled.  Recent studies have revealed vaping liquid  to have potentially toxic effects in human cells. A 2019 longitudinal analysis examined the association of chronic respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma) with e-cigarette use and concluded that “Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking.” 

In other words, vaping is harmful.

Conclusion

For these reasons, we join others in asking you to make vaping products less addictive and less attractive to children and youth.  Specifically, we ask you to:

1. Reduce the nicotine concentration levels from 66 mg/mL to 20 mg/mL.  Such a reduction would align Alberta with Nova Scotia and the European Union and probably soon British Columbia and Ontario.

Reason: Because of their very high concentrations of nicotine, vaping devices currently addict children and youth in a very short period.

2. Align Alberta’s treatment of vaping flavours with its treatment of cigarette and other tobacco product flavours.  Ban all flavours but tobacco. 

Reason: This strategy will help prevent children and youth from having a gentle first experience of vaping, being deceived by the candy or mint flavours into thinking that vaping is not harmful and vaping more, as flavours cause them to do.  Moreover, banning flavours will likely help adults move toward cessation of nicotine use.

Please amend Bill 19.  There is no convincing evidence that vaping reduces smoking in adults.  Vaping introduces children and youth to smoking.  Vaping is harmful to adults, children and youth.

Thank you for serving Albertans and Alberta. 

Yours sincerely,

W. Ward Flemons MD FRCPC, Professor and Section Head, Respiratory Medicine, Department of Medicine, University of Calgary

On behalf of those whose names and qualifications appear below (n=67):

• Alain Tremblay, MDCM, FRCPC, FCCP, Professor of Medicine
  Division of Respiratory Medicine &Arnie Charbonneau Cancer Institute, Cumming School of Medicine – University of Calgary, Calgary, Alberta
• Rhea Varughese, MD FRCPC, Assistant Professor, Division of Pulmonary Medicine, Faculty of Medicine, University of Alberta, Edmonton, Alberta
• Ian Mitchell, Clinical Professor of Pediatrics, and specialist in children’s lung diseases, University of Calgary, Calgary, Alberta
• Eddy Lang, Professor and Department Head for Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Christopher Ewing, MD FRCPC, Pediatrics and Pediatric Respirology, Edmonton Alberta
• David Motiuk, MD, FRCPC, Cardiothoracic Radiologist, Lethbridge, Alberta
• Elizabeth McKoen, MD, CCFP, Westlock, Alberta
• Nicoelle Wanner, MD, CCFP, Medicine Hat, Alberta
• Kathleen Game, MD CCFP, Family Medicine, Rocky Mountain House, Alberta
• Sandy J. Murray, MD CCFP FCFP CIME Red Deer County, Alberta    
• Tessa Penrod, MD CCFP FCFP, Beaumont, Alberta
• Chauntille Munchinsky, MD CCFP, Red Deer, Alberta
• Kayla Feragen, MD, CCFP, Nanton, Alberta
• Dr Heather Gooden, MD, CCFP, FCFP, Chestermere, Alberta
• Mark Belletrutti, MD MSc FRCPC, Associate Professor, Pediatric Hematology, Department of Pediatrics, University of Alberta, Edmonton, Alberta
• Ruoh-Yeng Chang, MD, CCFP, Sherwood Park, Alberta
• Naomi Fridhandler, Obstetrics and Gynecology MD, FRCSC , High River, Alberta
• Dinesh Witharana, MD CCFP, Family Medicine, Spruce Grove, Alberta
• David W Johnson. MD, Professor, Cumming School of Medicine, Calgary, Alberta
• Natashka Pollock, MD PhD FRCSC, University of Alberta, Edmonton, Alberta
• Kerri A. Johannson MD MPH FRCPC Clinical Associate Professor of Medicine, Section of Respirology, University of Calgary, Calgary, Alberta
• Willis H. Tsai, MD, FRCPC, FAASM, Respirologist, (Clinical Professor of Medicine, Section of Respirology, University of Calgary, Calgary, Alberta
• Tannis Spencer, MD, CCFP, HBSc, Family Medicine, Edmonton, Alberta
• Rachel Lim MD FRCPC (Respirology) Calgary, Alberta
• Jonathan Liu, MD FRCPC (Respirology), Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Sachin R. Pendharkar, MD, MSc, FRCPC, Diplomate ABIM (Sleep), Associate Professor of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Aravind Ganesh, MD DPhil, Neurologist, Calgary, Alberta
• Francis Green, MBChB, MD, Emeritus Clinical Professor, Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Katherine Kasha, MD, CCFP, FCFP, Edmonton, Alberta
• Marielena DiBartolo, MD FRCPC Pediatric Respirologist, Associate Clinical Professor, Department of Pediatrics, University of Calgary, Calgary, Alberta
• Prafull Ghatage Professor in Obstetrics and Gynecology and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Maeve O’Beirne, Medical Director, Department of Family Medicine, University of Calgary, Alberta
• Christopher J. Doig, MD MSc FRCPC, Professor of Critical Care Medicine, and Community Health Sciences, University of Calgary, Critical Care Specialist, Calgary, Alberta
• Eric Leung, MD FRCPC,  Division of Respirology, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Brandie Walker MD PhD FRCPC, Medical Director, Calgary COPD and Asthma Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Dina Fisher MSc MD FRCPC. Medical Director Calgary Tuberculosis Services, Division of Respiratory Medicine, University of Calgary, Calgary, Alberta
• James Powell MD, FRCS, Orthopedic Surgeon, Calgary, Alberta
• Kevin Huntley MN NP, Pulmonary Medicine Nurse Practitioner, Clinical Adjunct Faculty of Graduate Studies and Nursing University of Calgary, Calgary, Alberta
• Jody M. Platt, MD, FRCPC (Pediatric Respirology), Calgary, Alberta
• Stephen Field, MD Division of Respirology, Clinical Professor of Medicine Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Jennifer Graham Wedel, MD, MSc, FRCPC, Pediatric Emergency Physician, Calgary, Alberta
• Jody Patrick, MD, FRCPC (Pediatrics) Calgary, Alberta
• Cheri Nijssen-Jordan MD FRCPC MBA CCPE, Paediatric Emergency Physician, Calgary, Alberta
• Patrick D Mitchell MRCPI MD, Calgary, Alberta
• Roger Galbraith MDCM, FRCPC. Pediatric Emergency Physician, Clinical Associate Professor, Cumming School of Medicine, University of Calgary, Calgary, Alberta
• Stan Bernbaum, MD, CCFP(EM),  Emergency Physician, Calgary, Alberta
• Christine Kennedy, MD, FRCPC, Paediatric Emergency Physician, Assistant Clinical Professor, Cumming School of Medicine, University of Calgary, Alberta
• Melanie Willimann BSc, MD.CM, FRCPC Paediatric Emergency Physician, University of Calgary, Calgary, Alberta
• Katie Anker, MD, Calgary Alberta
• Robyn Buna, MD FRCPC Pediatrics, Calgary Alberta
• Mukarram Zaidi MBBS, MSc, MD, MCFP, Calgary Alberta
• Yan Yu, MD MPP MBA CCFP, Family Physician, Calgary, Alberta
• Lara Cooke, MD, FRCPC, Associate Professor of Neurology, Head of the Section of Neurology, Department of Clinical Neurosciences, Cumming School of Medicine University of Calgary, Calgary, Alberta
• Ashley Gillson, MD FRCPC, Clinical Assistant Professor, Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta
• Cindy Lee, MD CCFP, Edmonton, Alberta
• Sandra Allison, MD, Public Health, Calgary, Alberta
• Lynnsey Frunchak, MD, CCFP, Family Medicine, Sherwood Park, Alberta
• Christine Gibson MD FCFP, Clinical Assistant Professor, Department of Family Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta
• Jacqueline Holm Jhass, MD, CCFP, St. Albert, Alberta
• Mark Schindel,  Anesthesiologist, Edmonton, Alberta
• Alyzée Sibtain. FRCPC, Radiologist, Red Deer, Alberta
• Ariane Fielding, MD FRCPC, Edmonton, Alberta
• Naomi Fridhandler Obstetrics and Gynecology MD, FRCSC , High River, Alberta
• Pascaline De Caigny, MD CCFP, Edmonton, Alberta
• Amber Peters MD, CCFP (CoE), Edmonton, Alberta
• Zoe Filyk, MD CCFP FCFP Family Physician, Calgary, Alberta 
• Dianne Fang, MD, CCFP, Calgary, Alberta