An Old War Revisited From Lung Cancer To Cardiovascular, Pulmonary and Neurological Diseases

Healthday

"Over time, this imbalance can play a significant role in causing certain illnesses including cardiovascular, pulmonary and neurological diseases, as well as cancer."

"We were surprised by the gravity of the effect that one vaping session can have on healthy young people."

"This brief vaping session [the basis of the research study] was not dissimilar to what they [study subjects] may experience at a party, yet the effects were dramatic."

"While there’s a perception that e-cigarettes are safer than tobacco cigarettes, these findings show clearly and definitively that there is no safe level of vaping. The results are clear, unambiguous and concerning."

Holly Middlekauff, professor of cardiology and physiology, David Geffen School of Medicine, UCLA

Oxidative stress levels as much as quadrupled after nonsmokers used an e-cigarette for just a half-hour, scientists found.   Shutterstock/Pavel Kant

New research published in JAMA Pediatrics concludes that a mere 30 minutes of vaping can result in an imbalance between free radicals (molecules which damage cells) and antioxidants (compounds which inhibit free radicals), elevating cellular oxidative stress. The result is the potential for a significant increase in cellular oxidative stress level, leading to the creation of an internal environment which can result in a range of illness, including cancer, over time.

Popularly considered to represent a safer method of consuming tobacco, e-cigarettes or vape pens, it would appear, are anything but. Detrimental developments in the body foreshadowing serious health issues result from the use of these devices meant to deliver nicotine and other chemicals in vapour form rather than smoke. 

The test devised by researchers led by Dr.Middlekauff at UCLA saw researchers recruiting 32 men and women between ages 21 and 33, divided into three groups. The groups were represented by 11 non-smokers, nine regular tobacco smokers, and a dozen e-cigarette smokers. Oxidative stress was measured by the research team through the collection of immune cells prior to and following the three groups having engaged in a 30-minute vaping period.

The researchers found that oxidative stress levels in non-smokers were two to four times higher than prior to the test, after the test subjects had vaped for 30 minutes. A similar increase was not seen in the other two groups, the theory being that the other study subjects had started from a higher baseline of oxidative stress stemming from their prior exposure as smokers and e-vapers which led to a less notable increase.

These findings sound the alarm respecting the safety of vaping, given the reality that vaping has become extremely popular among the young globally. In Canada, roughly15 percent of youth between the ages of 15 and 19 claimed to have vaped within a 30-day period, with 87 percent specifying a nicotine product. And while another 36 percent said they had initiated use of the devices on a casual basis, of those who had reported vaping, one-third owned to habitually vaping on a daily basis.

Researchers say the results suggest there is no safe level of vaping, Getty

Vaping Advertisements and Anti-Vaping Campaigns

"The FDA campaign on social media, it's great that it's there, but it's not changing the trend of high prevalence of pro-vaping content [on Instagram]."
"The FDA campaign just becomes a drop in the ocean, practically, because it's so hard to compete with the enormous volume of pro-vaping advertisements."
"That's one of the dangerous things, youth are very susceptible to any type of influence that is so well advertised. Their brains are still developing, it's hard to resist. They want to fit in and they want to be cool. All the marketing strategies are so well crafted in the pro-cigarette message."
Julia Vassey, researcher, UC Berkeley Center for Integrative Research on Childhood Leukemia and the Environment

"It's really concerning because we're worried about a new generation of young people who could become addicted to nicotine."
"We have faith that society and government overall will put the health of young people ahead of the interests of corporation and we'll see regulation in the near future to protect young people."
Lesley James, senior manager, policy, Heart and Stroke Foundation of Canada

A post from British e-cigarette Instagram influencer @elysiaalessia on the #vapenation hashtag page. elysiaalessia/ Instagram

E-cigarettes were originally marketed as a novel invention whose purpose was to help smokers break their addiction to cigarettes. It was advertised as a successful mechanism that, though using nicotine, was less harmful and would help smokers succeed in weaning themselves away from the infinitely more threatening habit of cigarette smoking. Since its introduction to the consumer market its popularity has risen exponentially, particularly among an audience not initially targeted; teens and young adults.

When manufacturers began flavouring e-cigarettes, their audience was definitely not mature adults. Teens were attracted to the fruit flavours, the catchy names and the attractive containers. And Instagram, a popular social web-posting platform, is rife with marketing advertisements, many of which show models and some celebrity figures soft-peddling vaping products. Awareness campaigns launched to warn young people and particularly teens of the injurious aspects of vaping languish in relative obscurity, against the huge proliferation of vaping advertisements.

The products still contain nicotine, a highly addictive substance known for its negative health consequences. The number of high-school students who responded to a recent U.S. National Youth Tobacco Survey, revealed their use of e-cigarettes over-doubled from 12 percent in 2017 to 28 percent in 2019. Repeated e-cigarette use has been shown through research to lead to lung and brain damage, spurring the U.S. Food and Drug Administration to launch a youth-oriented awareness campaign, The Real Cost.

Researchers from the University of California's new study published in Frontiers in Communication, analyzed hundreds of thousands of Instagram posts between 2017 and 2019 to determine whether the FDA campaign made an impact on social interactions with vaping. Lead author Julia Vassey explained that the study discovered the average amount of likes on pro-vaping Instagram posts rose in fact, since the FDA campaign began.

The UC Berkley team placed their focus on Instagram when they were informed from e-cigarette 'influencers' of their growing followers, with some of the influencers sharing their analytics data with the research team which then understood that around 15 percent of followers of pro-vaping accounts were of the ages between 13 to 17. Each pro-vaping hashtag published over 500,000 new posts monthly while #The Real Cost published a mere 50 a month in a like time frame.

Using a "deep learning" software, the research team analyzed over 40,000 vaping posts on Instagram enabling the identification of each image's contents, to discover that the most popular e-cigarette marketing posts featured female models using vapes or alternatively, male models doing tricks with the vaping products.

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In Canada, Health Canada advertises risks related to vaping on their own website, but in addition hosts seminars in high schools, engaging with teens aged 13 to 18 through activities. Where, since 2018, their advertisements on the dangers in vaping have also appeared on social media sites like Facebook, Snapchat and Twitch. After viewing ads from Health Canada's outreach program, 26 percent of youth responded they would stop vaping, while 72 percent of teens who took part in the in-person school activities stated they were less likely to start using vapes and more likely to stop if they were already vaping.

Its a steep uphill battle in a social media world inhabited by teens, where 11 million posts confront them on line, produced by e-cigarette marketing teams and influencers, purposed to lure them into the vaping market, when posts published to inform the same demographic of the dangers and risks inherent in vaping number 3,000. The odds are 10,000 to one, which goes quite a way to explaining how marketing has made such inroads in the youth population, while health regulators continue to explore avenues to counteract their advertising successes and help teens realize the larger picture and their choices, gambling with their health.

At Your Own Risk, Chinese e-Cigarettes

"Once the national standard comes out, I can follow its targets and make big investments."
"I won't have to worry that something will happen, but now I don't know which day the sword would fall."
Ou Junbian, owner, Sigelei, e-cigarette exporter

"We can guarantee that they [cannabis e-cigarettes] are safe to be consumed through the stomachs, but is it safe enough to be absorbed through the lungs?"
"To be honest, in this respect, neither we nor the industry has evidence that is particularly solid."
Jiang Xingtao, director of flavors, RELX, e-cigarette seller

Reuters

China, in response to a vaping boom among young Chinese, is preparing to mandate compliance by producers of e-cigarettes to standardizing ingredients and manufacturing. With the establishment of a "national standard", producing companies are expected by law to provide details on the number and dosage of ingredients, to place warnings on packages and to devise methods of testing e-cigarettes, ensuring compliance.

Up to the present, the government of China has permitted the industry free rein, enabling them to thrive, no supervision by any government agency to ensure quality and safety. The vast country has over 9,500 e-cigarette production companies many with haphazard quality controls, resulting in knockoffs, unsafe ingredients and leakage of vape liquid. Vaping oils with nicotine levels higher than the package states were produced by eight of those companies.

Obedience to the new guidelines will have the effect of production costs increasing, a circumstance likely to result in hundreds of small e-cigarette exporters going out of business. The new standards when brought into law will have an opposite effect for most manufacturers since clear guidelines will ensure that manufacturing companies who comply may then legally sell their product in the vast Chinese market.

This is an industry that has viewed China as a haven, where ninety percent of the world's e=cigarettes are made. High-profile venture capital funding has invested hundreds of millions in some of the nation's top e-cigarette brands such as RELX, FLOW and Yooz. Chinese e-cigarette exporters have seen their sales drop precipitously to the United States in the wake of vaping-related health crises where thousands of American users have become seriously ill, and 47 have died.

Coincidentally, the domestic market which began to open up three years earlier appears to have taken up the slack, with an increasing interest in vaping in China. An estimated ten million Chinese e-users has turned Beijing's attention to the popular pastime, mostly young people among whom it is appealing to vape sleek devices with flavours such as chilled strawberry and orange soda.

China's e=cigarette market alone was valued at $750.4 million in 2018, according to global market research consultancy, Euromonitor, almost triple the 2014 valuation. Of a population of close to 1.4 billion people, there are over 300 million smokers. Vaping among the young has raised public concern, urging that regulations be drawn up and put into law and into practise to ensure public health safety in vaping.

It was revealed in early November on the website of People's Daily, the Communist Party's official news organ, that most e-cigarette companies went on selling their products online in defiance of the ban. China Central Television, the state broadcaster, filmed Beijing authorities calling on e-cigarette companies to comply with the ban and a day later Alibaba's Taobao and JD.com., two of the nation's most popular e-commerce platforms, no longer listed their availability.

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

That Nicotine Buzz

"A kid can inhale it and get a good nicotine buzz."
"Is this a fad or is it the beginning of primary nicotine addiction?"
"We think most users are  using it a few times a month. But there are clearly some who are using it every day."
Dr. Neal Benowitz, San Francisco

"Perhaps it will be a passing fad. We don't know."
"But, when kids come to you and tell you that half the kids are JUULing, it's a valuable piece of information."
"Obviously, there's a certain allure, and that's interesting and worrisome."
Robert Reid, deputy chief, division of prevention and rehabilitation, University of Ottawa Heart Institute

"To me, these are products that are really appealing to kids. ... Millions of kids are trying these e-cigarette products. Studies show that one in five eighth-graders that currently use tobacco products got there by starting with e-cigarettes."

"So these e-cigarettes are also a gateway for traditional tobacco use for many young kids.There are warnings on the labels of some vape liquids containing nicotine that are pretty clear: 'Nicotine is an addictive chemical; For use by adults 18 and older'." 

Joseph Allen, assistant professor of exposure assessment science, Harvard T.H. Chan School of Public Health

"Our main concern is adults having the tools that they need to quit smoking. Young adults, if they are not smokers, they absolutely should not start using a nicotine product."

"Spend some time in a vape shop and see the customers that come in for these wildly named products. They are adults. They are over 25 years old, and they are the same type that watches 'Family Guy' on Sunday nights."

"It's something that is a little lurid, appeals to adults. We're not a country of serious, uptight people that just want straightforward products."

American Vaping Association President Greg Conley

 

"I definitely think about ... how it affects what I'm putting into my lungs, because I don't really know too much about it. ... I'm not even sure how it turns into vape. ... But I haven't been too concerned about it, obviously, because I'm still using it [since first starting to vape in her teens]."

"It [warning label on her JUUL box, read for the first time] says 'California Proposition 65 warning: This product contains chemicals known to the state of California to cause cancer or birth defects, or other reproductive harm.' OK, I never read that before. Doesn't make me feel great, but that's what it says, so, I guess, yeah, that is the only warning. But that's probably the only warning that needs to be on there."

"[Did the warning change her mind about vaping?] No, definitely not."                      Bella Kacoyannakis, 20, East Longmeadow, Massachusetts

Twenty-year-old Bella Kacoyannakis started vaping when she was still in her teens

According to the company that produces the "Apple of vaping" -- the device that has spread through high schools in the U.S. and Canada as well as university dorms -- headquartered in San Francisco, it has one interest only, to improve the lives of smokers, to aid them in their determination to stop smoking cigarettes, nothing more, nothing less. Dr. Benowitz, whose clinic happens to be located several blocks from the JUUL headquarters, notes when he met the company founders three years earlier his message to them was: "You have to make sure this doesn't spread through high schools."

Spread it has; like the proverbial firestorm of popular acclaim for a product whose allures has taken young people always on the lookout for the latest cool attraction, by storm. The past decade has seen a notable decrease of young smokers, a situation that has gone into reverse with the introduction of e-cigarettes and vaping devices causing health authorities to pose hard questions, according to Dr. Benowitz, an expert on nicotine toxicology, speaking at a national conference on smoking cessation held in Ottawa, Ontario.

Students outside West Carleton Secondary School in Ontario hold e-cigarettes. (Hallie Cotnam/CBC)

A recent survey of teens and substance abuse throughout the province found ten percent of Ottawa high school students had vaped in 2017, in comparison to six percent who said they had smoked. The recent nature of this phenomenon means that little is as yet understood about whether young users do so socially, or whether as time goes on they will become confirmed cigarette smokers, becoming lifetime users of nicotine. This is an issue identified as worrisome by physician and University of California professor, Dr. Benowitz.

Admittedly, the hit of nicotine delivered through e-cigarettes is acknowledged to be less harmful than that from cigarettes. Public Health England points out that e-cigarettes are 95 percent less harmful than cigarettes, and some British and French jurisdictions have enlisted vape store personnel as advisers for smoke cessation. The danger rests in the smoke, according to research. Sweden, with its high use of snuff-like smokeless tobacco, "snus", lists a low rate of lung cancer.

Concerns remain, however, that devices like JUUL differ from those first-generation e-cigarettes since JUUL uses nicotine salts, diminishing that harsh taste but delivering high nicotine content. Flavours used for vaping products such as mango and creme brulee may appeal to adult smokers but these are flavours that young smokers also respond positively to. And while vaping may be less harmful than smoking, concerns abound about nicotine's effects on the still-developing adolescent brain.

A vape trick video has over eight million views on YouTube. (Posted to youtube by vAustinL)

Chilling Out With the Latest "Cool"

"The bottom line is the JUUL is the best example of a technology that delivers nicotine more efficiently."
"This is a genuine phenomenon. Everyone would like this to be a fad. The concern is that this fad involves a highly addictive drug in the form of nicotine."
"I've been in a corner store at the Slurpee machine with my kids and there's a 10-foot banner overhead [advertising vaping products]. It took 20 or 30 years to get rid of cigarette displays. They reach everyone who goes into the store."
"Flavour is [a] big driver for kids. It's what gets into their mouths. And then nicotine takes over."
David Hammond, professor, School of Public Health and Health Systems, University of Waterloo

The JUUL vaping device is rechargeable, easy to conceal and has a sleek design, all features that appeal to youth. Julie Oliver / Postmedia

"[JUUL was founded] with the goal of providing a satisfying alternative for adult smokers", the company states, but of course it's hardly debatable that 'adult smokers' would be drawn to such flavours as 'unicorn horn' and 'cereal milk', putting the lie to the company's feeble declaration of honourable intent. While tobacco smoking among adults is no longer as prevalent as it once was, nicotine-product manufacturers have been diligently exploring methods that would be attractive to a new generation.

Formerly known as Philip Morris Companies Inc., now Altria Group Inc., seeing a new wave of users enthusiastic for nicotine delivered in a modern, neat and streamlined package, have responded somewhat predictably by buying in to this new phenomenon through a 35-percent stake in JUUL Labs late last year, paying out close to $13-billion for the privilege. JUUL is a battery-powered, rechargeable device designed to heat a "Pod" or cartridge of "juice" containing flavouring and nicotine; the resulting vapour is what users inhale.

"I don't know if youth know how much nicotine is in them. They're consuming an entire cartridge in one shot."
"It's an emerging issue. We want to tackle it as soon as possible. We don't want to be dealing with it fifty years down the line."
"For some [users], getting fined will be a deterrent. Others can be convinced of the danger of nicotine because their parents smoke, and they've seen what it did to their parents. And some can be convinced that they're the targets of marketing, and they don't like it."
"Each school has its own culture. In some schools, there is little vaping. In some, it's in the bathrooms. In others, it's under the trees."
"For youth, tech is interesting. They can build their own. There are thousands of different kinds of juices and flavours. You can conceal it if you want [clouds of vapour], or don't conceal it if you don't want to."
Dana Periard, project officer, Ottawa Public Health, tobacco control and prevention

Ads for vaping devices in an Ottawa convenience store. Julie Oliver / Postmedia

In the city of Ottawa, Canada's capital city, bylaw officers take "enforcement action" when students are found to be illegally using vaping devices on school grounds. A bylaw office can issue a fine of $490 to anyone selling or supplying a vapour product to someone under the age of 19. The Ottawa Catholic School Board has given the authority to its schools to remove doors from school washrooms to more readily enable staff to determine what is happening there; vapour is a dead giveaway. Schools have also been authorized to issue fines of $305 to students caught vaping indoors.

The Smoke-Free Ontario Act, amended in October to include vaping, enables school principals to call in bylaw officers to attend to vaping students. "I am extremely confident that the removal of washroom doors and the issuing of fines will discourage those tempted to vape or smoke indoors", commented the principle of one school in the Catholic School Board. In contrast to that move, the public school board has no plans to remove washroom exterior doors but does provide evidence statements to bylaw officers enforcing no-vaping regulations.

The new fad of school bathroom vaping seems to have occurred as a virtual overnight sensation as the JUUL brand name made its way into the high school lexicon as a tempting foray into disobeying adult authority to the extent that teens now refer to school washrooms as the "JUULroom". The device is attractive to youth challenging authority; its sleek look, ease of use, readily concealed size make it irresistible to slip in "pods" delivering flavoured nicotine salts.

A single pod contains nicotine equivalent to 20 cigarettes. Teens vaping an entire pod at a time become nauseous from overconsumption of nicotine, leading the new lexicon to expand with the inclusion of "nicking out". Professor Hammond has been receiving emails from school principals across the country seeking advice. Close to 21 percent of high school seniors claim to have vaped in the past month in 2018 where in 2017, that number was 11.7 percent.

The U.S. Surgeon General Jerome Adams in December issued an unusual public health advisory addressing the "epidemic" of e-cigarette use among teens, fuelled by new types of e-cigarettes recently entering the market. He noted that JUUL experienced a 600-percent leap in sales in 2016 and 2017. Health Canada for its part announced a week ago a campaign to warn youth of the risks of vaping.

Recently a province-wide survey of teens and substance abuse revealed that ten percent of Ottawa  high school students in 2017 had vaped. In comparison, six percent of students had smoked. It is Ottawa Public Health's intention to work toward a goal that would see the "de-normalization" of vaping and to that end work with bylaw enforcement along with police and addiction counsellors is proceeding.

Vaping has the potential to assist adults who wish to stop smoking, by weaning them off tobacco, even while it presents as a risk to youth. E-cigarettes and vaping are acknowledged as less harmful than smoking so the potential is there to reduce risk for smokers as long as they commit to transition from cigarettes to e-cigarettes, according to the U.S. Surgeon General. The reality is, however, that a majority of adults who make  use of e-cigarettes do so only to supplement their regular cigarette smoking.

Photographs of JUUL vaping kit Julie Oliver / Postmedia