Comparing the Tobacco Death Toll to E-Cigarette Uncertainty

"[Using e-cigarettes is] exposing yourself to all kinds of chemicals that we don't yet understand and that are probably not safe."
"There's almost no doubt that [e-cigarettes] expose you to fewer toxic chemicals than traditional cigarettes."
Dr.Michael Blaha, M.P.H., director of clinical research, Ciccarone Center for the Prevention of Heat Disease, Johns Hopkins Medicine

"As a safer alternative than smoking for people addicted to nicotine, [e-cigarettes] are analogous to prescribing methadone for people addicted to opioids, a strategy called harm reduction."
Dr.Sally Satel, The Vaping Overreaction, The Atlantic

"As a doctor who takes care of people who use drugs, I don't have a problem with people who use drugs."
"But there are so many people in this country who really hate them and don't care if they die. Or don't care if they are able to have lives of dignity and respect."
Dr.Kimberly Sue, Harm Reduction Coalition, New York and California

"The Canadian market is six to twelve months behind where we thought it would be."
"Sales of recreational cannabis are not living up to expectation. We built an incredible team here, and an incredible company."
Mark Zekulin, CEO, Canopy Growth, Canada

Photo by Amelia Holowaty Krales / The Verge

The U.S. Centers for Disease Control and Prevention announced over 2,100 cases of lung injury linked to e-cigarettes or vaping reported in the United States as of Wednesday. Canada has been waiting to see whether instances of pulmonary disease linked to vaping would be found among Canadians and instances are now emerging in Quebec, New Brunswick, British Columbia and Ontario. "The Public Health Department in collaboration with its doctors, is currently investigating [the latest case reported this week in Quebec]. The person was consuming legal nicotine-based products", added the statement.


In the U.S. the steadily emerging cases of lung disease attributable to vaping, has pointed at vaping pens bought on the black market, where the pens' ingredients included vitamin E acetate, forbidden in Canada as an ingredient in e-cigarettes. But the legal market in Canada has not taken off to the extent of expectations. The causes are diverse; though recreational cannabis has been legal for over a year, too few commercial retail outlets have been granted licenses, and their prices are substantially higher than products available on the black market.

The U.S. Centers for Disease Control and Prevention named "e-cigarette, or vaping, product use associated long injury (EVALI)", claiming to have detected "a potential chemical of concern in biologic samples from patients with EVALI". The identification of the chemical in fact, has been in the public domain for quite awhile. The addition of vitamin E acetate in some black market vaping products containing the canabinoid THC suggests risks of vaping can be ameliorated by avoiding black market products.

On the other hand, the latest identified case of lung injury in Quebec associated with vaping was said to have been acquired with legally-bought product which presumably was free of vitaimin E acetate. And then there is the perspective of harm and product and usage comparisons. Traditional cigarette smoking according to the CDC is the cause of over 380,000 deaths yearly in the United States, as opposed to the total number of reported vaping-related lung injuries standing at 2,100, with 39 deaths.

The evidence is strong that vaping cannabis products is infinitely safer than the use of traditional tobacco-filled cigarettes. Ideally, habitual smokers are encouraged to quite their habit of their own volition, and not to rely on a substitute as a crutch to enable them to move toward smoking cessation. Vaping, as a stop-smoking technique is not encouraged until and unless one's own efforts unaided by such devices fail, according to the Johns Hopkins Medical Center.

Yet the use of e-cigarettes is fairly universally recognized as a less health-dangerous treatment for tobacco addiction than the continuation of cigarette use. The horrendous death count linked to cigarette use seems to be accepted with a measure of equanimity, yet the far fewer lung disease presentations and even smaller number of deaths associated with pulmonary disease has sent shockwaves through the vaping and medical community.

The casual attitude toward vaping that saw a widespread take-up has been replaced in some quarters with suspicion and avoidance, except for attitudes among the youth generation who have taken up vaping with great enthusiasm, as a social recreational tool, not as a transitional tool away from cigarette use. In fact, there are fears in the medical community that vaping among teens will proceed to regular cigarette use.

"[Doctors found an] enormous amount of inflammation and scarring [on the teen's lungs]."
"This is an evil I haven't faced before. The damage that these vapes do to people's lungs is irreversible. Please think of that — and tell your children to think of that."
Dr.Hassan Nemeh, surgical director, thoracic organ transplant, Henry Ford Hospital

"We asked Henry Ford doctors to share that the horrific life-threatening effects of vaping are very real!" 
"Our family could never have imagined being at the centre of the largest adolescent public health crisis to face our country in decades."
"Within a very short period of time, our lives have been forever changed. He has gone from the typical life of a perfectly healthy 16-year-old athlete — attending high school, hanging out with friends, sailing and playing video games —  to waking up intubated and with two new lungs, facing a long and painful recovery process as he struggles to regain his strength and mobility, which has been severely impacted."
Family of 17-year-old teen transplant patient

A Michigan teenager was the recipient of what could be the first double lung transplant on a person whose lungs were severely damaged from vaping, health officials said Tuesday. (Tony Dejak, File/Associated Press)

Tobacco/Cannabis Health Alert

"We are not seeing the potential benefits [of e-cigarettes helping adult smokers quit regular cigarette smoking], but we are taking the potential risks [in seeing an increase in teen use of e-cigarettes]."
"Your lungs are much more sensitive than digesting it [vaping cannabis oils] through  your stomach. No one knows what the contaminants are in these oils."
"If you are buying something on the black market, then all bets are off."
David Hammond, chair, Canadian Institutes of Health Research in applied public health, University of Waterloo

A woman smokes a Juul e-cigarette in New York. The company says its product is intended for adults who already smoke and never people who are underage. (Brendan McDermid/Reuters)

In Canada between 35,000 and 45,000 deaths attributed to smoking take place annually, with roughly 30 percent of those deaths occurring from cancer. Recreational drug use in Canada includes the three legal products including tobacco, vaping and cannabis, though regulators have yet to fully comprehend the interplay that the three manifest on public health. Cannabis and vaping, newer to public health concerns than tobacco, are now posing challenges of their own.

Challenges that David Hammond, speaking at the biennial Canadian Cancer Research Conference taking place in Ottawa, addressed in his capacity as chair of Health Research in applied public health. In both the United States and Canada, the sale of e-cigarettes has seen a sharp increase, and a large proportion of that increase reflects new sales to teen users.

The conundrum is that despite the expectations that e-cigarettes having the capacity to aid adult smokers cease the use of regular cigarettes, no parallel increases in e-cigarette use has been realized among that adult smokers' demographic. A strong association exists among  youth, however, between vaping first and then proceeding onward toward smoking cigarettes.

Juul opened its first retail store in Toronto this summer. (Albert Leung/CBC)

Dr. Hammond points out that this disparity might arise given youths' propensity to be attracted to risky behaviour, and once one risk-taking behaviour has been absorbed, the next one beckons. Dr. Hammond earlier in the year had led a study that discovered an increase in vaping by Canadian youth. Among 16- to 19-year olds an 8.4 percent vaping increase was reported in 2017, which had additionally increased to 14.6 percent in the like period, August to September by 2018.

A 15-year-old high school student uses a vaping device. (AP Photo/Steven Senne)

Until recently, teen smoking had been observed to be on the decline. This study pointed out an increase in youth smoking regular cigarettes between 2017 and 2018, from 10.7 percent to 15.5 percent, with vaping seen as introducing youth to regular smoking. This was viewed as the first data to emerge since major tobacco companies launched and advertised e-cigarette brands in Canada in the wake of the adoption of Bill S-5, legalizing e-cigarettes with nicotine in May 2018.

Though admittedly e-cigarettes are viewed as less harmful than smoking -- in particular with cancer risk -- the inescapable fact is that they contain nicotine. E-cigarettes are only useful for regular smokers when an entire switch is made from cigarettes to e-cigarettes. For those who choose to smoke both e-cigarettes and to continue with regular cigarettes, little or no risk reduction results from that combination.

In the United States there  have been close to 2,000 serious cases of lung disease related to vaping cannabis oils, with over 30 deaths, thus far. An estimated 80 percent of the cases of that mysterious lung disease point to vaping cannabis oils, mostly acquired through the black market. The Canadian Cancer Society back in June called on government action immediately, to address the increase in youth vaping.

The Canadian Cancer Society wants Saskatchewan to raise to legal age of purchasing tobacco and vaping products to 21. (Aliaksandr Barouski/Shutterstock)

Storm of Assurances Heading Your Way

"Although it's going to be critical for us to ensure that we look at all of our input materials and we get specific analysis to make sure there are no additional contaminants in the product, we must remember we are in a highly regulated environment in Canada where consumer safety comes first."
Greg Engel, CEO, Organigram Inc. licensed producer

"Legal extract product will be stringently tested for contaminants like heavy metals and solvents, which is not a process done with black market product."
HEXO Corp., licensed producer

"While the FDA does not have enough data to presently conclude that vitamin E acetate is the cause of the lung injury, the agency believes it is prudent to avoid inhaling this substance."
U.S. Food and Drug Administration

An e-cigarette store, in Wilkesboro, N.C., 2016. George Etheredge/The New York Times

"There is still insufficient information to comment specifically on the media reports coming out of the United States, but we believe that the mix of information underscores how important it is for governments to create regulated frameworks for cannabis vape products. None of Canopy Growth's vape devices will use vitamin E acetate."                                                                                                                      Jordan Sinclair, Canopy Growth Corp.

"I think what we are seeing now is one of the first real debates around the formulation of vape products and whether, even legal products are actually safe for public consumption."
"I think it's still much too early to see the impact of this health scare on consumer demand, but there is an optic of safety in vaping where consumers believe it is a safer option to combustion. That may change."
"Vape pens, both cannabis and nicotine, became popular so quickly and it was hard for governments to say, 'No, we're not going to legalize that', when they were seen as an alternative to cigarettes."
"Because it is such a new product class and because the environment has been evolving so quickly, the adoption rate of these products moved faster than the science did, to help us understand what the different compositions of these vape products could mean for the health of consumers."
John Kagia, executive vice-presdent, industry analytics, New Frontier Data, cannabis research firm

A man uses a vape as he walks on Broadway in New York City.   Reuters/Andrew Kelly/File Photo

Just when cannabis vape products are on the cusp of becoming legal in Canada, comes news from the United States of issues no one might ever imagine would eventuate, with lung illnesses presenting at hospitals and diagnoses linking them with vaping. Six people have died, and altogether close to five hundred people in 33 American states have been affected. This is a serious turnaround from the euphoria people experienced with the relaxing of state laws, making marijuana possession legal, and Canada's federal legalization of cannabis.

The mysterious lung condition presenting in the U.S. has completely mystified investigators. What is known is that one of the deaths linked to cannabis oil was purchased in Oregon from a legal pot shop. While no one can definitively point to the exact cause of the development of respiratory problems in hundreds of vapers, the U.S. Food and Drug administration has singled out vitamin E acetate as a culprit. Its use is that of a suspension fluid in cannabis vape pens.

So for producers of vaping devices it seems abundantly clear that vitamin E acetate is not to be used. The use of "vitamins and colouring agents" in vaping products is banned by Health Canada through its Tobacco and Vaping Products Act. Any ingredients in a vape pen besides flavouring agents, according to Health Canada, should reflect pharmaceutical quality. All this, despite that there is no proof as yet that vitamin E acetate is responsible for the adverse health condition flare-ups.

Alexander Mitchell’s lungs had stopped working and he was in intensive care on two different life support systems for about a week — he escaped death, but two others did not. Mitchell Family / Washington Post - supplied

What is certain, however, is that health authorities at the state and federal levels in both countries respectively have seen fit to issue warnings on the effects of nicotine- and cannabis-infused vape devices. That, since 2015 when vaping was first introduced and became a popular trend, it has been embraced by teens, and that truly has the health community concerned; neither nicotine nor the psychoactive ingredient in pot bodes well for the future health of the young, impacting the lungs and the still-developing brain.

Data collection in Canada is in its early stages in determining whether an emerging problem similar to what the United States is experiencing has visited Canada as well. Nor whether the problem has links to the illegal vape pen market. And nor is there any data yet available on the long-term use of vaping pens for either product -- for irrespective of the promises of safety by licensed producers, no reliable longitudinal data exists, suggesting vaping as a safe form of consuming cannabis.

"Sure, many of those who have reported breathing problems might have bought vape devices from the illegal market, and you really don't know what goes into them, but at the same time you just don't know the long-term effects of vaping cannabis consistently. If the industry is saying it is safe, they actually don't know that themselves", pointed out Jacob Borodovsky, epidemiologist at the Washington University School of Medicine in St.Louis.

Since November enforcement action has been taken against some 130 students in regards to vaping on school grounds. These are just some of the vapes and vape products confiscated by schools and turned over to By-law. Postmedia

The situation can also be useful to the legitimate industry in cautioning consumers that the only way to be absolutely safe is to purchase products solely from legal sources. This has presented licensed producers with the opportunity to tout the safety and reliability of their highly regulated products as a safe choice for anyone concerned with avoiding the possibility of unknowingly compromising their health by frequenting the illegal market.

"I think it's too early for us to comment on whether this concern over vaping is going to affect sales. But I can tell you that for us, the biggest priority is to ensure safe, consistent access for the consumer and you will get that from the legal market."
"Vapes are becoming the preferred method of consumption, and it would be disingenuous of us to do anything except fully understand the regulations and try to abide by them."
Tim Pellerin, general manager, PAX Labs for Canada

In this Aug. 28, 2019 photo a man exhales while smoking an e-cigarette in Portland, Maine. Health Canada says people who vape should get medical attention right away if they're worried their electronic cigarettes are harming them. Robert F. Bukaty / THE ASSOCIATED PRESS

Delivering Nicotine : Diagnosing Lung Disease

"I think people will be sensitive and there will be a heightened awareness [resulting from American research linking vaping to lung disease]."
"[The situation in Canada is] like the wild west [currently, for vaping]. What is troubling is the complete absence of any form of regulation."
"[The epidemic of respiratory illnesses now recognized in clusters in the U.S. will result in] a whole new generation of addicts, many of whom will turn to nicotine products."
Dr.Andrew Pipe, Ottawa Heart Institute

"The Government of Canada will continue to monitor all available data sources for indications of similar issues in Canada and will take action, as appropriate, to protect the health and safety of Canadians."
Maryse Durette, spokesperson, Health Canada

"These [lung illnesses discovered in the U.S. with people vaping contaminated THC-based products] are fundamentally different from the nicotine vaping products that millions of people worldwide have been using in place of lethal cigarettes."
David Sweanor, chair, advisory board, Centre for Health Law Policy and Ethics, University of Ottawa

"[Non-smokers and young people should not vape] However, vaping is a less harmful option than smoking for Canadians who already smoke tobacco products."
"Smokers who switch completely to vaping can significantly reduce their exposure to many toxic chemicals found in tobacco smoke."
Health Canada

Vaping Nam Y. Huh / THE ASSOCIATED PRESS

In 2017, one quarter of high school students in Ottawa have claimed they experimented with e-cigarettes, and the general consensus is that since then that number has likely increased. According to Robert Schwartz, executive director of the Ontario Tobacco Research Unit, professor at the University of Toronto Dalla Lana School of Public Health, research indicates a clear link between advertising and promotion and e-cigarette use. The current promotion and advertising with JUUL Labs as an example, is geared toward youth.

The colourful, playful packaging, the youth-oriented flavours are all attractants specifically for a young market. And that market is responding with enthusiasm. Research by the Ontario Tobacco Research Unit demonstrates exposure to advertising to be sky-high in Ontario: "Just about everybody is exposed", stated Mr. Schwartz. And with that exposure, rates of vaping among youth who have never before smoked is increasing in Ontario as well as in other provinces, a situation concerning to school officials and health authorities alike.

Evidence of harm from vaping, including its negative effects on the lining of the respiratory system leading to young people accustomed to vaping, coughing and wheezing twice as frequently as non-users is pointed to by Dr. Schwartz. Tens of thousands of young people who have vaped are now becoming addicted to nicotine, thanks to the flavours attractive to teens. Now that the news of hundreds of instances of severe lung disease in the U.S. flagged as linked to vaping has alerted Canadian health authorities, a new spotlight on vaping has emerged.

Most lung illness cases now under investigation in the United States, a death included, involved youth and young adults, leading Canadian health experts like Dr. Andrew Pipe to calling out for more stringent rules on advertising and packaging and promotion of e-cigarettes. In the United States, certain flavours of the JUUL products have been banned on the basis of their appeal to children and teens, whereas no such preventive action has been taken in Canada.

There is little research into the long-term effects of vaping. Phil Noble / REUTERS

Dr. Michael Siegel, a professor in the Department of Community Health Sciences at Boston University School of Public Health points out that in each instance of lung disease, oil-based THC and not the alcohol-based liquids in most e-cigarettes has been identified. He takes exception to the U.S. Centres for Disease Control advising youth and young adults to avoid e-cigarettes altogether, insisting this bias places lives at risk by not singling out the specific product causing harm; instead causing general alarm that will result in moving people away from a safer alternative to smoking.

Dr. Pipe, on the other hand is concerned with evidence pointing to some e-cigarette products delivering greater amounts of nicotine into the system than cigarettes. Where a pod -- the system that JUUL uses to deliver nicotine and flavour -- contains the equivalent of 20 cigarettes' nicotine content. With reports of teens vaping an entire pod at a time, this rings alarm bells for him.

A man poses for a picture as he vapes at a vape shop.

Daniel Becerril | Reuters