Health matters

“You just don’t victimize smokers twice,” said Gopal Bhatnagar, a practicing cardiac and thoracic surgeon in Toronto.

“You don’t make something that’s hyper-addictive freely available to people and then you victimize them again by saying well you know there’s a technology that has the ability to help you get off this… but we’re going to restrict that,” said Bhatnagar.

From 2005 to 2013, he was the Chief of medical staff of the Trillium Health Centre—a collection of three of hospitals in the Toronto area. After stepping down, Bhatnagar was looking for a hobby. He first came across the electronic cigarette in reading an article online. He found it intriguing, but was hesitant of anything that used the word “cigarette”.

Yet after repeatedly seeing the devastating effects smoking had on his patients, Bhatnagar started learning more about the automated gadgets that supposedly helped millions of smokers quit.

He spent six months reading through scientific articles and calling other shop owners. The more he read on the topic the more certain he became of the effectiveness of the product.  He brought a group of young entrepreneurs together to start an online site that sold e-juice and e-cigarettes. The group met would meet with customers who were interested in quitting smoking, but wanted more information on the product, on an individual basis.

“We knew how shops ran, but wanted to emphasize the smoking cessation aspect, so [we] did not do lifestyle-oriented branding,” said Bhatnagar.

The online site became such a success the doctor decided to open his own vape shop in Toronto in the fall of 2013.

In August 2015 Public Health England – an organization overseen by the UK Department of Health – published a review of the latest e-cigarette research and concluded electronic cigarettes were 95 per cent healthier than regular cigarettes. The validity of this review has been questioned by some, who believe that the main studies referenced by Public Health England may have been funded by tobacco companies.

In a general survey, Public Health England found that more than 44 per cent of people believed e-cigarettes to be at least as harmful as regular tobacco cigarettes. The survey also found that the perception of electronic cigarettes is largely influenced by the stigma in media coverage of electronic cigarettes.

While there is a lack of research on e-cigarettes, there are many known facts about smoking which make vaping an attractive alternative. Smokers are two to four times more likely than non-smokers to develop heart disease or suffer a stroke. They are also 25 times more likely to develop lung cancer.

“Everybody who smokes wants to stop. The people that don’t want to stop are basically the people that have given up, who really feel there’s no hope in them stopping,” said Gopal Bhatnagar.

But not everyone agrees with the cardiologist.

Health fears

On the path to regulation of electronic cigarettes, the question researchers are trying to answer is what are the potential health risks for both the user and the public associated with vaping.

Licensed e-juices typically contain four ingredients: propylene glycol, glycerin, flavouring and occasionally nicotine, even though it is technically illegal in Canada.

Propylene glycol is an odourless, colourless chemical. It has very low toxicity in humans, and takes very large quantities to cause any noticeable harm. In fact, it is commonly used in food processing as an additive in frozen desserts, amongst other things. Propylene glycol poisoning does not usually occur unless it is being administered intravenously. It takes blood concentrations of five grams per litre or higher to cause poisoning, which can result in renal failure, seizure or even coma. The US Food and Drug Administration (FDA) sees propylene glycol as being safe.

Glycerin is also an odourless, colourless chemical, but it is completely non-toxic. As a liquid it is quite viscous, and very sweet. It is often used as a sweetener. Its consistency and sweetness make it ideal for e-cigarette use.

It’s still unclear how propylene glycol and glycerin react when heated and inhaled, but to date no evidence has shown these two substances to be harmful.

A 2015 Harvard University study found that some flavoured e-liquids contained known carcinogens. The chemical it was most concerned about was diacetyl, known to cause a rare disease called popcorn lung.

Popcorn lung—medically termed brochiolits obliterans—is an illness where the tiny air sacs in the lungs are scarred. This causes the patients to cough uncontrollably with overall shortness of breath. It is called popcorn lung because of an outbreak in a microwave popcorn plant in Missouri.  It was discovered that the popcorn used diacetyl to enhance the butter flavouring

Other reports, such as a 2015 University of North Carolina at Chapel Hill study, found some types of electronic cigarette vapour had the potential to negatively affect lung cells.

All of these studies have one thing in common: individual results have never been replicated or substantiated because the e-cigarette is still a relatively new product.

Smoking cessation

Health Canada does not permit electronic cigarette companies to make health claims about its products. Specifically, e-cigarettes are disqualified from being marketed as smoking cessation devices.

If a company does advertise its product as a smoking cessation tool, the devices must be evaluated by Health Canada to test the assertion about the product’s efficiency.

According to the 2015 study Public Health England, smokers who used electronic cigarettes were 60 per cent more likely to quit than those who tried patches, gums or nothing at all.

The subjects in the study used the products independently —i.e. without the help of a doctor or life coach.

Yet recent studies suggest e-cigarettes may not be as effective as the industry is claiming.

A January 2016 study out the University of California San Francisco used meta-data from more than 38 studies on e-cigarettes. It found that smokers who use electronic cigarettes are 28 per cent less likely to quit smoking compared to people who did not use the product.

“E-cigarettes make it harder to quit smoking,” said Stanton Glantz, professor of medicine and director of the UCSF Center for Tobacco Control Research and Education.

Harm reduction

One of the biggest mistakes people make when talking about smoking cessation is that they judge or blame the smoker, said pulmonologist and director of the smoking cessation program at McGill University Health Centre, Sean Gilman.

“Cigarette companies have deliberately made this addictive,” he said.

Instead, he said, society should treat tobacco dependence as a condition.

“It’s a chronic condition, just like diabetes or asthma,” said Gilman.

Gilman said he had no official position on how officials should regulate the product. But he said, as a doctor, his priority and greatest concern was to help his patients—and that means getting smokers off of tobacco cigarettes. E-cigarettes have helped several of his patients do that.

“And for that goal, it’s an excellent tool,” he said.

Bhatnagar has a similar approach. “I always tell people if you don’t smoke don’t start. If you do, do anything you can to stop,” he said.

While there is discord as to whether electronic cigarettes should be officially classified as smoking cessation devices, they could potentially decrease the actual number of cigarettes a smoker smokes.

It could, as Sweanor suggested, contribute to a form of harm reduction. Specifically, electronic cigarettes for smokers could be what clean needles are to heroin addicts.