Meeting on May 14-15, 2018: Scientific Advisory Board on Vaping Products

Ottawa, ON

Attendees
Dr. Carolyn Baglole
Dr. Linda Bauld
Dr. Geoffrey Fong
Dr. Maciej Goniewicz
Dr. Lorraine Greaves
Dr. David Hammond
Dr. Steven Hoffman (Chair)
Dr. Rachel Tyndale
Mr. James Van Loon (Executive Secretary)
Dr. Kenneth Warner

Regrets
Dr. Andrew Pipe

Secretariat
Ms. Dana Beaton
Dr. Samir Khan
Mr. Jean-Michel Lévesque
Ms. Fatima Mussa
Ms. Amy Wilson

Observers
Dr. Hanan Abramovici
Dr. Robin Churchill
Mr. Mathew Cook
Mr. Graham O'Brien
Ms. Erin Rutherford

Meeting Summary

  1. On May 14-15, 2018, members of the Scientific Advisory Board (SAB) on Vaping Products met in Ottawa for their second meeting. The agenda is attached in Appendix I.
  2. On the first day, the Chair of the SAB, Dr. Steven Hoffman, welcomed participants and provided an overview of the agenda. After the inaugural meeting in the fall of 2017 the board was asked to work on three specific tasks in advance of this meeting:
    • To review and provide recommendations to Health Canada on potential authorized statements for the promotion of vaping products regarding the relative health risks of these products in comparison with tobacco products.
    • To review the proposed content of Health Canada's web page, which aims to provide Canadians with information on vaping and vaping products.
    • To develop a forward research agenda based on existing knowledge gaps.
  3. The Executive Secretary, Mr. James Van Loon, provided an update on the development of Bill S-5, An Act to amend the Tobacco Act and the Non-smokers' Health Act and to make consequential amendments to other Acts. Since the last meeting of the SAB in fall 2017, the Bill was studied by the House of Commons Standing Committee on Health (HESA), which proposed amendments to the bill including a total prohibition on lifestyle advertising. Prior to the amendment, Bill-S5 prohibited lifestyle advertising with selective exemptions, including in places where youth are not permitted by law. The amendments removed the exemptions, thus prohibiting all lifestyle advertising. At the time of the meeting it was expected that Bill S-5 would receive royal assent in the coming days.
  4. The SAB highlighted that lifestyle advertising can be interpreted differently and questioned how Health Canada was going to implement this regulation in the absence of a clear definition of lifestyle advertising. Health Canada indicated that Bill S-5 provides a definition of lifestyle advertising, which includes examples. Health Canada will monitor closely how the market evolves upon legalization of vaping products and react accordingly to these observations.
  5. Mr. Van Loon also provided an overview of Budget 2018 commitments related to tobacco products, including additional funding to support the federal tobacco control strategy, and an increased excise tax on cigarettes.

  6. Dr. Lorraine Greaves shared her expertise with the SAB by presenting on the relationship between sex, gender and vaping. Dr. Greaves provided an overview of sex and gender and outlined the frequent lack of understanding concerning these multidimensional factors. Dr. Greaves provided examples of how sex, gender and other diversity traits significantly influence human behavior and biological mechanisms in the context of tobacco and vaping products use. She also presented on how sex and gender based messaging have been used to target specific user groups such as women and youth. Finally, Dr. Greaves identified research gaps and proposed that existing research evidence on tobacco use and vaping could be re-analyzed from a sex and gender based lens and the findings leveraged to inform the SAB recommendations.
  7. SAB members unanimously agreed that sex and gender are important factors to consider in all future work of the SAB on vaping. Given the current dearth of studies focusing on sex and gender in the context of vaping, the SAB agreed that research exploring these factors should be prioritized. Dr. Greaves will provide an update on the findings of her ongoing systematic review on sex, gender and vaping at the next meeting, scheduled for November 2018.

  8. As agreed during the inaugural meeting of the SAB, Ms. Dana Beaton presented Health Canada's latest national vaping surveillance and market data. The presentation included data from national surveys, as well as the findings from public opinion research and vaping market studies. Ms. Beaton provided an overview of vaping behaviour, risk and harm perception and the use of flavored products. Health Canada will provide an update to the SAB at the next meeting as the 2016-17 Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS) survey results will be available and will also continue to present data analysis as other new data sets become available.
  9. After the first round of presentations, the SAB was asked to focus on the first task on the agenda: to review and provide recommendations to Health Canada on potential authorized statements for the promotion of a vaping product regarding the relative health risks of these products in comparison with tobacco products. Health Canada provided a scene-setting presentation explaining how relative risk statements fit within the proposed Tobacco and Vaping Products Act (TVPA) and the regulatory process going forward, then presented the proposed statements. The objectives of these defined statements are twofold:
    • To prevent the public from being deceived or misled with respect to the health hazards of vaping products
    • To protect young persons and non-users of tobacco products from inducements to use vaping products

    The SAB expressed concerns on the 180 day delay between Royal Assent of Bill S-5, which immediately legalizes the manufacture and sale of nicotine-containing vaping products, and the lapse between when the promotion restrictions for health benefits and certain flavors would come into force. Health Canada explained that this delay is necessary in order to allow time for industry to adapt their packaging to conform to the new legislation. The TVPA would also restrict false or misleading marketing 180 days following Royal Assent.

    The SAB was asked to react to the potential authorized statements, including assessing their scientific validity and accuracy. Recommendations included:

    • Avoid using the term "smoking" without specifying the type of product referred to (e.g. tobacco products) to avoid confusion in the context of cannabis legalization.
    • Remain as short and simple as possible to avoid misinterpretation by a universal audience due to the use of technical or scientific terms.
    • Remain prudent when referring to the potential harms of using vaping products to reflect the lack of clear scientific evidence on the effects of vaping on human health and the need for more research to be done on this matter. To this end, statements should use modal verbs such as "may" and "could" when referring to the potential harms of vaping products.
    • Clearly distinguish that potential harm reduction is due to the action of tobacco smoking cessation and not due to the use of vaping products themselves, when these products are used as a tool to help quit smoking tobacco.
    • Take into consideration that any of these authorized statements could be taken out of context and therefore become misleading.
    • Be adapted over time as new scientific evidence becomes available.

    The SAB reached consensus on some statements for Health Canada to consider in the development of their authorized statements on vaping products.

  10. The second day of the meeting opened with a presentation from Dr. Linda Bauld on vaping for smoking cessation in priority groups. Dr. Bauld presented a systematic review of the limited literature available on the use of vaping products as a tool for smoking cessation in vulnerable groups. She presented a UK perspective on the matter as well as data on e-cigarette use by socio-economic gradient. In addition, Dr. Bauld presented evidence from recent UK studies on the effectiveness of e-cigarette use for smoking cessation among vulnerable groups, such as out-patients with schizophrenia, individuals who are incarcerated and individuals with lung cancer. While evidence on the widespread effectiveness of using e-cigarettes for smoking cessation is limited, recent studies show encouraging results that highlight the promise vaping products may have in helping to reduce smoking rates in groups where tobacco use is still common and/or cessation is particularly challenging. SAB members thanked Dr. Bauld for sharing her expertise and noted the importance of leveraging emerging research on vulnerable groups to inform the work of the SAB.
  11. The SAB was then asked to focus on the second task for this meeting: to review the proposed content of Health Canada's web page, which aims to provide Canadians with information on vaping and vaping products. Health Canada provided a draft of the web page content to the SAB, which included revisions SAB members had made in advance of this meeting. The SAB made additional recommendations for Health Canada's consideration, including:
    • That the first content of the page highlight key messages targeted to both smokers and non-smokers.
    • That Health Canada split the content into two web pages, one targeted for non-smokers and another for smokers, in order to ensure that relevant information is easily accessible for each of these populations.
    • That Health Canada develop infographics to present the information in a format that is easier to read and understand for a universal audience. Health Canada explained that infographics are unfortunately not used due to accessibility issues.
  12. During the first day of the meeting, SAB members had agreed that a discussion on the potential warning messages on vaping products packaging should be added to the agenda. Health Canada presented the proposed labelling requirements for vaping products to support the objectives of the proposed TVPA, in particular: to enhance public awareness of the health hazards posed by using a vaping product. Health Canada also specified that under the Canada Consumer Product Safety Act other warnings will be required, such as a "skull and cross-bones" icon on any vaping liquid product packaging containing nicotine. The SAB cautioned that given the current limitations of scientific evidence and consensus on the potential health harms of using vaping products, Health Canada could consider voluntary warnings for product packaging that specifically reference the lack of conclusive evidence on the matter. These warnings could eventually evolve and become mandatory as new scientific evidence on the health impacts of vaping is generated. Further, the SAB recommended that any warning that is to be incorporated on product packaging should also be communicated in product advertising to ensure that consumers are fully informed. Additionally, the SAB advised Health Canada on the potential harms for children who could drink vaping liquid refills. Health Canada informed the SAB that the Consumer Chemicals and Containers Regulations will require child-resistant containers for e-liquid refills.
  13. Finally, the SAB began a discussion on developing a forward research agenda to address knowledge gaps in the area. The Chair emphasized that the collaboration of Health Canada and the Canadian Institutes of Health Research (CIHR) on this advisory board represents an opportunity for the SAB to not only provide advice on the regulation of vaping products but to also inform research priorities to address knowledge gaps concerning vaping products and associated health effects in Canada. CIHR presented a summary of research recommendations proposed by Public Health England (PHE) and the National Academy of Science, Engineering and Medicine (NASEM) in early 2018. Based on these observations, the SAB was asked to 1) discuss priority research agenda options for the Canadian context and 2) identify mechanisms to prioritize Canadian investment in research on vaping. In order to make the best use of limited resources, the SAB recommended that elements that are unique to the Canadian context be prioritized. These include:
    • Canada's unique regulatory framework for vaping products, including:
      1. industry's reaction to the TVPA
      2. surveillance and market data
      3. context of parallel cannabis legalization in the country
    • Use of vaping products by Canada's Indigenous populations and other vulnerable populations
    • Sex and Gender Based Analysis (SGBA+)

    The SAB also recommended that Health Canada consider making vaping market and surveillance data accessible to researchers.

  14. In closing, Dr. Hoffman reflected on the second SAB meeting, summarized key takeaway messages, and thanked the presenters. The SAB confirmed that the third meeting will take place on November 19-20, 2018 in Toronto. Proposed agenda items for this meeting include a continued discussion on the research agenda, Health Canada's presentation on 2016-17 results of the CSTADS and an update from Dr. Greaves on her systematic literature review of on sex, gender and vaping. Dr. Hoffman adjourned the meeting and thanked the board for their willingness and efforts to guide and advise on this important area.

Appendix I - Meeting Agenda

Scientific Advisory Board on Vaping Products

Meeting #2 - May 14 & 15, 2018

Day 1

8:30-10:00 Introduction

  • Welcome - Chair: Dr. Steven Hoffman
  • Brief Introductions/Roundtable - All
  • Health Canada Update - Mr. James Van Loon

10:00-10:15 - Break

10:15-11:30 Presentations

  1. Sex, Gender and Vaping- Dr. Lorraine Greaves
  2. National Vaping Surveillance & Market Data - Ms. Dana Beaton

11:30-12:00 Task#1: Promotion Regulations

  • Introduction of Task

12:00-1:00 - Lunch

1:00-2:30 Task #1: Continued

  • Guided Discussion & Recommendations

2:30-3:00 - Break

3:00-4:30 Task #1: Continued

Day 2

8:30-9:30 Presentation

9:30-10:00 Task #2: Public Vaping Messages

  • Vaping for Smoking Cessation in Priority Groups - Dr. Linda Bauld

10:00-10:15 - Break

10:15-11:00 Task #2: Continued

11:00-12:00 Task # 3: Forward Research Agenda

12:00-1:00 - Lunch

1:00-1:30 Conclusion and Next Steps

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