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Meeting Summary - November 1-2, 2021: Scientific Advisory Board on Vaping Products

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Organization: Health Canada or Public Health Agency of Canada

Date published: February 2024

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Meeting Summary

  1. On November 1-2, 2021, members of the renewed Scientific Advisory Board (SAB) on Vaping Products met virtually for their second meeting. The agenda is attached in Appendix I.
  2. The meeting opened on Day 1 with remarks from the Chair, Dr. Steven Hoffman, Scientific Director of the Canadian Institutes of Health Research's Institute of Population and Public Health (CIHR-IPPH). Dr. Hoffman welcomed participants and acknowledged the board's gathering took place virtually and across Indigenous lands, including the land of the traditional unceded territory of the Algonquin Anishinaabeg People. Dr. Hoffman announced the departure of Dr. Ann McNeill and the addition of two new members to the board, Jamie Hartmann-Boyce and Dr. Michael Pesko.
  3. The SAB Executive Secretary, Dr. Sonia Johnson, Director General of the Tobacco Control Directorate at Health Canada, provided a scene-setting presentation. Dr. Johnson presented a snapshot of the impact of tobacco use, a brief diagnostic of tobacco and vaping products use and associated health risks in Canada, and an outline of current federal actions on tobacco and vaping product control. In Canada, smoking prevalence has decreased over time, including among youth smoking rates have decreased significantly in Canada. However, youth vaping rates increased significantly between 2017 and 2019, and remain unchanged through January-April 2021. Youth vaping rates remain a concern for the Canadian government, which has taken a number of steps to address youth vaping through strengthened regulatory controls (including the Vaping Products Labelling and Packaging Regulations, Vaping Products Promotion Regulations, and Nicotine Concentration in Vaping Products Regulations) and enhanced compliance and enforcement.
  4. Following Dr. Johnson's presentation, the Chair moderated a brief question period. Members inquired about compliance and enforcement of restrictions to online sale of vaping products, new data to measure the impact of the COVID-19 pandemic on youth vaping, the status of proposed restrictions on e-cigarette flavours, and the management of tobacco industry participation in consultative processes led by Health Canada.
  5. Dr. Nancy Rigotti provided a presentation titled "Balancing Considerations of the Risks and Benefits of E-Cigarettes". Dr. Rigotti presented various forms of evidence, such as randomized control trials, population studies, and sales data on cigarettes and e-cigarettes, indicating that e-cigarette use can increase smoking cessation. Furthermore, she presented evidence from studies examining the health risks of vaping, which suggests that e-cigarette use is far less hazardous than combustible cigarette smoking. Dr. Rigotti also presented evidence related to key concerns about youth vaping, including nicotine addiction, smoking initiation by non-smoking youth, and nicotine harm to brain development. Dr. Rigotti emphasized the need for balance, noting that the public health objective should be to develop policies and interventions that both reduce youth vaping and support adult smoking cessation. Examples of such policies and interventions include higher tax on combustible tobacco products and lower tax on e-cigarettes; retail sale of flavored e-cigarettes limited to adult-only outlets; and nuanced, targeted communications emphasizing realistic concerns about youth vaping and the potential benefits of e-cigarettes as smoking cessation aids for adult smokers.
  6. Guest presenter Dr. Ken Warner, Professor Emeritus of the University of Michigan, provided a presentation titled "Modelling Public Health Impacts of Vaping". Dr. Warner presented the application of the Mendez-Warner model, a dynamic population simulation model that tracks groups of individuals, differentiated by gender and smoking status, to assess smoking prevalence and its mortality consequences over time. In the presented application of the model, his findings suggest that while vaping is highly likely to have substantial, positive net impact on public health (millions of life years saved and millions of e-quitters), vaping is not likely to be the "magic bullet" that will end smoking. The anticipated impact is significant but modest compared to the burden of smoking. Dr. Warner encouraged health policy makers to consider vaping as one more tool in the armamentarium of smoking cessation interventions.
  7. Guest presenter Dr. David Levy, Professor at Georgetown University, provided a presentation titled "Estimating the Public Health Impact of Cigarette and e-Cigarette Use". Dr. Levy discussed how the modeling of public health impacts of cigarette and e-cigarette use has become increasingly complex, given numerous companies in different markets, multiple distribution channels, and use of different and multiple nicotine delivery products. Dr. Levy outlined the Smoking and Vaping Model (SAVM) and SimSmoke, two models used to examine the public health impact of cigarette and e-cigarette use: SAVM estimates the public health impact of individuals switching from cigarettes to nicotine vaping products; SimSmoke simulates the dynamics of cigarette smoking rates and smoking attributable deaths, and the effects of policies on those outcomes. An explicit SimSmoke e-cigarette model for Canada is currently being developed, funded by Health Canada. Dr. Levy concluded that it will be important to monitor the impacts of policies (cigarette-oriented and e-cigarette-oriented), as well as environmental changes, including COVID-19, on market structure and patterns of product use.
  8. The SAB engaged in a roundtable discussion moderated by the Chair. Members were invited to consider the following key research questions:
    1. Do benefits outweigh harms? Do harms outweigh benefits?
    2. Are we asking the right questions and defining the right parameters?
    3. How do we evaluate net impact to inform a regulatory response from the Government of Canada?
  9. Members discussed the strengths and limitations of e-cigarette modeling, including the variability of the context, different policy outcomes, and the need to consider socio-economic disparities among users. While modeling can provide suggestive evidence, it does not provide definite answers to these important questions. Members highlighted the need for recent data to better understand vaping product use at the population level and further evidence on the correlation between vaping product use and smoking cessation. The challenge ahead will be measuring the long-term trend of reduction in youth smoking. Available data suggests that e-cigarettes sales among youth have gone up, but prevalence numbers have remained unaffected during the last 18 months. Members also expressed caution in minimizing the health effects of vaping product use based on evidence from pre-clinical studies. Further evidence is needed on the health implications of vaping product use. Equity must also be considered during e-cigarette modeling. Less advantaged population groups are more likely to benefit from e-cigarette use as an alternative to traditional cigarette use.
  10. Members also discussed Canada's regulatory approach to e-cigarette flavours and the potential impact of flavour restrictions on youth vaping. Members unanimously agreed that the regulatory approach must aim to limit youth uptake while making vaping products accessible for adult smokers. While regulating vaping products as medicinal products rather than commercial products may prevent youth uptake, such a regulatory approach may impact (or reduce) e-cigarette facilitated smoking cessation for adult smokers. It is also important to place fewer restrictions on the sale of vaping products than there are for the sale of combustible cigarettes.
  11. Dr. Jamie Hartmann-Boyce provided a presentation on the Cochrane review of e-cigarettes for smoking cessation. Using the Cochrane Tobacco Addiction Group's Specialized Register and the Cochrane Central Register of Controlled Trials, Dr. Hartmann-Boyce and her team compiled relevant studies to examine the effectiveness, tolerability, and safety of using electronic cigarettes to help people who smoke achieve long‐term smoking abstinence. Findings indicate that use of nicotine e‐cigarettes can aid in smoking cessation for a period of at least six months is consistent across several comparisons: e-cigarettes with nicotine are more effective than non-nicotine e-cigarettes and nicotine replacement therapy (moderate certainty evidence); and e-cigarettes with nicotine are more effective than behavioural support only or no support (very low certainty evidence). No studies included in the review showed serious adverse events. There is a need for more evidence on the effects of e‐cigarettes, particularly the effects of newer types of e‐cigarettes that have better nicotine delivery.
  12. Following Dr. Hartmann-Boyce's presentation, the board engaged in a round table discussion moderated by the Chair. Members discussed the following points:
    1. The need for research conducted through randomized controlled trials to examine the impact of e-cigarette flavours on smoking cessation. Members suggested the possibility of creating incentives for the industry to conduct these trials.
    2. The need to obtain Canadian population-level data on smoking cessation and the importance of sharing this data with the broader academic and scientific communities.
    3. The possibility of creating a model wherein the tobacco industry conducts studies and submits the data to regulators with no industry interpretation.
    4. While e-cigarettes can facilitate smoking cessation, it is important to not forget to utilize and optimize other clinically supported options for smoking cessation, such that people who smoke are supported using all tools available.
    5. The evidence regarding use of vaping products for smoking cessation among youth is not strong. Clinical success with youth usually involves a holistic approach, including elements such as family support, changing environment, extracurricular involvement, etc., which are not captured in controlled studies.
  13. Day 2 of the meeting opened with a presentation from Dr. David Hammond on trends in youth vaping and factors associated with initiation, sharing findings from the International Tobacco Control Youth Tobacco and Vaping Survey. Dr. Hammond presented preliminary research findings on changes in prevalence of vaping among youth in the United States, Canada, and England following the COVID-19 outbreak and noted differences in the profile of youth vaping behaviors between the countries. He also studied the impact of the regulatory approaches of the countries, with a focus on flavour restrictions, the indicators of dependence, and devices and vape brands most frequently used by youth.
  14. Following Dr. Hammond's presentation, the board engaged in a round table discussion moderated by the Chair. Members discussed the increased levels of nicotine addiction among youth and the difficulty of measuring the market size due to the various means through which young people are purchasing vaping products, including specialty shops, convenience stores, and online retailers. Members discussed flavour restrictions and nicotine concentrations limits on vaping products and various means of measuring the impact of these regulatory interventions. Members suggested that effective flavour bans would likely reduce appeal of vaping to youth, while nicotine concentration limits would likely assist with addiction. Members also raised concerns about the impact of limiting nicotine concentrations on cessation rates in adults who smoke and the potential of self-titrating nicotine. Members discussed additional forms of regulations, such as limiting modifiable vaping products, and the concern of users manufacturing their own vape flavors potentially resulting in negative health consequences. The environmental impact of disposable vaping products was also discussed.
  15. Dr. Trevor Mischki provided a presentation on the most recent Canadian data on vaping among adults and youth. Dr. Mischki provided an overview of vaping product and combustible cigarette use patterns in Canada using data collected from the Canadian Community Health Survey and the Canadian Tobacco and Nicotine Survey. Dr. Mischki noted that smoking rates in Canada vary by demographic and socioeconomic characteristics, such as employment status, age, and province/territory. While recent evidence shows that smoking rates have declined since the onset of COVID-19 pandemic, vaping product use rates have remained unchanged from late 2019 to April 2021. Anticipated new data on vaping will enable further socioeconomic analysis in this area.
  16. The Chair led a round table discussion and invited members to discuss vaping as a net harm/benefit and critical data gaps. Members discussed the difficulty in achieving the right level of regulation to balance discouraging youth uptake and encouraging cessation for adult smokers. The over-regulation of vaping products, comparatively to combustible cigarettes, has led to a misinformed public belief that vaping products are more harmful than combustible cigarettes. Members stressed that combustible cigarettes must be regulated more strongly than vaping products and emphasized the need to reset the public perspective of the risks of vaping products. Members proposed the following actions:
    1. Increase purchase age (differentially) for combustible cigarettes and vaping products, and prioritize enforcement
    2. Increase taxes (differentially) for combustible cigarettes and vaping products
    3. Develop specific policies to reduce accessibility (differentially) of combustible cigarettes and vaping products for youth
    4. Engage with public health agencies to provide information and messaging regarding relative risks of various nicotine products, e.g., messaging directed at youth to decrease appeal of vaping products
    5. Consider incentives for industry to submit vaping products via pharmaceutical pathway
    6. Develop guidelines for health professionals to recommend vaping products as smoking cessation aids
    7. Develop product standards, i.e., criteria that vaping products need to meet to be sold (either as commercial products or pharmaceutical products)
    8. Invest in research
  17. Members also highlighted the need to approach vaping as a vehicle rather than a substance and to engage in cross-substance discussions with policy makers. Many young Canadians are using vaping products to consume cannabis. This creates significant difficulties to regulate both areas simultaneously. Conversations must go across substances in order to achieve effective policy and regulation.
  18. Nick Neeley of Health Canada provided the board with an update on the legislative review of the Tobacco and Vaping Products Act (TVPA). Mr. Neeley provided background on the enactment of the TVPA in 2018 and the legislative review mandate requiring the Minister of Health to review the provisions of the TVPA periodically as outlined in the Act. He presented the scope of the first review, which will focus on the Act's vaping-related provisions. The review will assess operation and application of the Act in relation to its objectives, and examine evidence that has emerged since 2018, in order to determine whether the authorities in the Act are sufficient to address emerging issues and concerns. He invited members to review a draft of the consultation document, which will be launched for public consultation early in 2022.
  19. In closing, Dr. Hoffman and Dr. Johnson reflected on the second SAB meeting, summarized key takeaways and thanked presenters and members for engaging discussions. Dr. Hoffman adjourned the meeting and thanked the board, presenters and attendees for their participation.

APPENDIX I – MEETING AGENDA

Scientific Advisory Board (SAB) on Vaping Products

Meeting #2 – November 1st and 2nd 2021

Day 1

11:00am – 11:30am: Introduction

11:30am – 12:40pm: Do benefits outweigh harms? Do harms outweigh benefits?

12:40pm – 1:10pm: Break

1:10pm – 2:10pm: Discussion period moderated by Chair

2:10pm – 2:55pm: Role of vaping in smoking cessation

2:55pm – 3:00pm: Wrap up of Day 1

Day 2

11:00am – 12:30pm: Current state of vaping in Canada and vaping initiation among youth

12:30pm – 1:00pm: Break

1:00pm – 2:25pm: Vaping as a net harm or benefit

2:25pm – 2:45pm: Update on review of the Tobacco and Vaping Products Act

2:45pm – 3:00pm: Conclusion

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