The Electronic Cigarette Use in Canada – Local and Global Considerations

Abstract

Since its invention in 2003, electronic cigarettes’ (EC) users have been growing worldwide. ECs were first introduced in the market in Canada in 2004, and they remained illegal until 2018. ECs were initially marketed as a safer and cleaner alternative for the traditional combustible smoking and smoking cessation measures. Statistics show that EC use prevalence is the highest among the youths (15–19) and adolescents (20–24) years of age. EC has to promote cessation as it supplies nicotine to smokers prevent nicotine withdrawal syndrome and reduce motivation to continue smoking. EC use becomes a gateway to tobacco use and nicotine addiction. Nicotine exposure to youth and adolescents can damage the developing brain. EC use is also associated with an increased heart attack rate and other health problems. There are various reasons for using ECs, such as curiosity, quitting combustible smoking, or cutting down the number of cigarette use. Many people start ECs use before the age of 19 years. Majority of vapers like fruit flavor. Dual combustible cigarette smoking and EC use is a burning issue globally, including in Canada.

1. Introduction

Cigarette smoking is the primary cause of preventable deaths in Canada [1]. From 1960 to 2015, traditional combustible cigarette smoking prevalence has reduced from 50 to 13% in Canada [2] which is a good sign for public health. Even though, electronic cigarette (EC) is emerging in the Canadian general population which is a public health threat in this generation. The majority of Canadian EC users start smoking during their adolescence period.

Image credit: Pixabay.

EC also known as e-cigarettes or “vape,” is vaporized nicotine, cannabis, or only flavored products contained in a battery-powered electronic nicotine delivery device. EC use has increased in recent times globally, which has also been used as an alternative to combustible cigarette smoking. Since the invention of EC in 2003, its availability, popularity, and use have been widely growing [3]. ECs were first introduced in the Canadian market in 2004 and became legal in 2018. They were initially marketed as a safer and cleaner alternative to traditional combustible cigarettes and are used extensively for smoking cessation and relapse prevention [4]. ECs are typically considered a harm reduction strategy as they involve vapor that contains a smaller amount of toxic chemicals than the traditional combustible cigarettes [3, 5]. However, this impression is misleading, erroneous, and meant for marketing purposes.

The prevalence of EC use is varied and increasing globally, specifically in high-income countries, including Canada. The prevalence is reportedly higher in adolescents (15–19 years) and youths (20–24 years) [2, 3, 6, 7, 8]. For instance, in the US, current EC use was 11.7% in 2017 and reached 27.5% in 2019 [9]. In the UK, EC use was 1.7% in 2012, arose to 7.1% in 2019 [10]. Similarly, in Eastern Europe- EC use in Russia was 33.4%, Slovakia 34.4%, and Lithuania 55.6% [11]. In the middle East, studies in the University students in Saudi Arabia found the prevalence of EC use between 10 and 27.2% [12]. According to the European Commission, EC use prevalence in European Union countries ranges between more than 0.2% to less than 7% [13].

According to the Canadian Tobacco, Alcohol, and Drugs Survey, in the general Canadian population aged 15 years or older, the prevalence of past-30-days EC use was 3%, it was 2% in 2013, and that of ever tried EC was 15%, which was 9% in 2013. The prevalence was higher among youths and young adults over the period [6, 7, 8]. In the US, the past 30 days EC use was 11.7% in 2017 and reached 27.5% in 2019 [9].

The public health impact of EC use is attached to its effects on conventional smoking and health risks. ECs are recommended in harm reduction programs for cigarette smokers as an alternative to traditional tobacco or a cigarette smoking cessation measure [14]. EC can promote smoking cessation as it supplies nicotine to cigarette users and prevents nicotine withdrawal syndromes, which reduces motivation for conventional cigarette smoking. However, its effectiveness for smoking cessation is controversial, given the range of smoking outcomes reported by research- some smokers quit smoking by switching to EC, some become dual users, and remaining smokers quit tobacco and discontinue EC use [2, 15]. Furthermore, EC use as a measure of smoking cessation seems relevant to adult smokers as most youths and young adults who use ECs are non-smokers. Although the evidence around the health benefits and risks of EC use is unclear, the use of EC by smokers as a harm reduction or smoking cessation measure may gain health benefits. However, EC use may increase among non-smokers, former smokers, and dual users [16]. Alternatively, EC use may serve as a gateway for cigarette smoking initiation [2, 6, 15].

Image credit: Pixabay.

The prevalence of past-30 days of EC use was 14% among non-smoker youths and 11% among non-smoker young adults in Canada [6]. Various systematic reviews and longitudinal studies reported strong associations between EC use and the subsequent smoking behavior, whereby youths and adolescents who use EC have more than two times increased intention to cigarette smoking in the future than those who do not use EC [2, 17]. Therefore, the increased prevalence of EC use is a critical public health concern because, in addition to its health risks, it may interrupt the declining trends of cigarette smoking over the past decades and may add to the future population-level burden of cigarette smoking.

2. Some facts about ECs

Fact # 1. ECs are battery-operated devices that mimic the smoking experience using an inhalation and heating process, which vaporizes the e-liquid within the device. The e-solution differs in composition, but mostly propylene or vegetable glycol or can contain other ingredients and flavors. It may or may not contain nicotine.

Fact # 2. ECs containing nicotine are legal for adults 18 years and older in the Canadian market.

Fact # 3. Evidence shows that ECs are less harmful than conventional tobacco smoking [18].

Fact # 4. The previous study demonstrated few potential benefits to ECs as a smoking cessation device, but current research remains inconclusive. The body of evidence is fast-growing and shifting in this area of research [19, 20].

Fact # 5. Evidence shows that it would be less harmful to cease smoking entirely rather than dual-use.

Fact # 6. Individual who has tried other cessation methods and have not had success try ECs. Individuals who failed to quit smoking would be better off using ECs over the long term rather than continuing to be smoking a combustible cigarette.

Fact # 7. Health concerns such as long-term inhaling propylene or vegetable glycol and the effects of exposing second-hand smoking are not established yet.

Fact # 8. EC use is associated with an increased risk of heart attack, and both conventional cigarettes and ECs are associated with multiple threats of heart attack to the individual [6].

Fact # 9. There is evidence of child poisoning and accidental exposure, and consumption of e-liquid is on the rise [21].

Fact # 10. Evidence shows that nicotine exposure to youth and adolescents can damage the developing brain [22, 23].

Fact # 11. Emerging evidence proved the potential for ECs to be a gateway to tobacco use and nicotine addiction [24, 25].

Fact # 12. Marketing and promoting ECs are common; primarily, youths are targeted with attractive flavors.

Fact # 13. Research showed that ECs could renormalize and undermine tobacco control and smoking cessation efforts [26].

Fact # 14. ECs are appealing to youth. 23% of students in Canada reported having ever tried ECs. More teens are using ECs [8].

Fact # 15. Various jurisdictions in Canada address EC use in public places to support tobacco control and support clean air initiatives.

Fact # 16. The most common type of EC use in Canada is dual use-where an individual both vapes and smokes combustible tobacco [7].

Fact # 17. 38.6 million EC users live in the countries where EC sales are allowed, 9.5 million in those places where EC use is completely banned, and 10 million live in those areas where EC use has no specific laws [27].

3. Global estimation of EC use

ECs are potentially disruptive innovations for human health. According to the Global Adult Tobacco Survey, which was last conducted in 2017 from 49 countries around the globe found, the number of EC users was 40.3 million [27]. It was estimated that the remaining 152 countries belong to 17.8 million EC users, which gives a total of 58.1 million people who used ECs in 2018. As Jerzyński et al. (2021) projected that among EC users, 2.1 million belong to low-income countries, 7.7 million belong to lower-middle-income countries, 19 million belong to upper-middle-income countries, and 29.3 million belong to higher-income countries. Looking at the above global statistics, it is seen that more than half of EC users live in high-income countries. Likewise, let us compare these numbers region-wise. 4.1 million EC users reside in the African region, 4.2 million in the Eastern Mediterranean region, 4.6 million in the South-East Asian continent, 11.2 million in the Western Pacific area, 15.3 million in the European region, and 18.7 million in the Americas region [27].

4. EC use and legal status in Canada

ECs with or without nicotine are legal in the Canadian market now. In May 2018, Bills S-5: An Act to amend the Tobacco Act and Non-Smokers’ Health Act received Royal Assent, which established a new legislative framework to regulate the manufacturing, sale, labeling, and promotions of vaping products in Canada. Sales of vaping products containing nicotine are permitted to adults 18 years and older in Canada. A Canadian study found that more teens use ECs as they see them as fun [28].

5. Age at initiation of EC

According to the Canadian Tobacco and Nicotine Survey (CTNS) [8], 30.57% of males and 31.54% of females initiate EC before 19 years in Canada. From the age group of 20–24 years, male numbers are higher than females. Interestingly, after 45 years of age, more females started EC use than males, which is 21.34% and 17.08%, respectively [8].

6. Causes of EC use

There are numerous reasons for using ECs in Canada. Many Canadians use ECs than prescription medications to quit smoking and nicotine replacement therapy. According to CTNS [8], among Canadians aged 15 years and over who used EC in the past 30 days, the most commonly reported causes were smoking cessation (27%), curiosity (20%), and enjoyment (20%). The generally reported reasons among youth aged 15 to 19 years who used ECs past 30 days were curiosity (29%), enjoyment (29%), and reducing stress (21%). In the young adults who used ECs in the past 30 days, the most common reasons were curiosity (27%) and smoking cessation (20%), while among adults aged 25 years and above, the most common causes were smoking cessation (41%) and avoiding returning to smoking (15%). After looking at the above statistics, we can conclude the following reasons for EC use in Canada:

• Curiosity, just wanted to try it,

• For enjoyment/pleasure,

• To reduce stress or self-calm down,

• To quit combustible smoking,

• To cut down on smoking cigarettes,

• To use where cigarettes are not allowed or permitted,

• To avoid returning to cigarette smoking

• Peer pressure

7. EC and its flavors

When people visit vape stores or websites, they will find a wide variety of colorful pods, cartridges, and bottles (Picture below) filled with various flavored e-liquid. The vape juice is heated in EC devices, and then it creates an aerosol that vapers inhale and enjoy. Vape juices are available in different forms, such as bubble gums, tobacco, candy, and many more.

These flavors are available in the Canadian vape market [8].

• Fruit flavor 42.0%

• Mint or Menthol 17.8%

• Tobacco 13.5%

• No usual taste 9.7%

• Candy 5.6%

Some other flavors are also available in the market, such as dessert, kid’s cereals, and flavorless.

Picture credit: Google.

8. Patterns of ECs use in Canada

13% of Canadian people reported trying an EC in 2015 [2, 6, 7]. Youth (15–19 years of age) and young adults (20–24 years of age) were found to have the highest rate of trying ECs at a rate of 6.3% [8]. EC use dramatically increased between 2013 and 2015 [29]. Dual-use of combustible tobacco and ECs is a burning topic in Canada as it is the most common pattern of EC use among smokers [28].

9. EC use and health risks

There are insufficient studies to establish long-term health risks of ECs [11]. Nevertheless, there are various health risks and side effects of ECs recognized as follows:

• Nicotine addiction [30]

• Hypertension

• Acute inflammatory distress [31]

• Asthma [32]

• Lung Injury [33]

• Atherosclerosis [34]

• Cardiovascular disease [34]

• Headache

• Cough

• Dizziness

• Irritation of mouth and throat

• Nausea and vomiting

10. Sales and marketing of ECs

Legally the manufacturer cannot make a health claim regarding an EC product’s ability to aid in smoking cessation or suggest a safer alternative to smoking traditional combustible tobacco unless Health Canada approves the statements. Bill S-5 has prohibited the promotion of flavors too. The legislation also gave the regulatory authority to Health Canada to mandate the application of consumer information, including health warning messages on vaping products. Similarly, the marketing of vaping product has been prohibited in Canada through bill S-5. Nevertheless, it is not that difficult to find online and using other social media platforms. Smokers think that it is their right to smoke in public places, thinking ECs are socially accepted products free of stigmatization and guilt. This positioning is concerning as ECs are being marketed to undermine the hard-fought change in social norms related to tobacco use, thus undermining the progress in tobacco control.

Moreover, there are no location-based restrictions for vaping product advertisements. Though banned in Canada, celebrity ECs endorsements are common, and celebrities often use ECs in entertainment programs, which act as an indirect endorsement. Increasing globalization and the advancement of the digital era means that Canadians can be exposed to EC marketing from countries where regulations are nonexistent or less comprehensive. ECs are rapidly growing in the Canadian market [20, 29].

11. Conclusion

EC use has emerged in present days all around the globe. EC was first introduced in the Canadian market in 2004, becoming legal after 14 years. Initially, it was marketed as a safer and cleaner alternative to the traditional tobacco smoking and relapse prevention tool. The prevalence of EC use is rising in high-income countries, including Canada, and most users are adolescents and youths. The increased prevalence of EC use is a critical public health issue because it may interrupt the declining trend of cigarette smoking; as a result, it may increase the future population-level burden.

EC with or without nicotine is legal in Canada; however, it is illegal for a manufacturer to make a health claim regarding EC product’s ability to aid in smoking cessation or suggest a safer alternative to traditional tobacco smoking. Many Canadians initiate EC use before 19 years of age. Canadians use EC for various reasons, such as curiosity, enjoyment and cutdown, and traditional smoking. There are a wide variety of tastes of ECs available in the Canadian market. There are not enough scientific studies to establish the long-term health risks of EC use. Nevertheless, several health risks are documented, including nicotine addiction, cardiovascular diseases, and lung injuries.