In the Race to Regulate E-Cigarettes, Smokers May Be Forgotten
While there are serious, unanswered questions about the health risks of e-cigarettes, critics warn that overly strict regulations may discourage cigarette smokers from making the switch from the more dangerous product.
Ray Yeates always assumed he would die a smoker. An adherent of Alcoholics Anonymous with over 35 years hard-fought sobriety, the 66-year-old says that when he found out that Bill W., one of AA's founders, had continued to smoke through emphysema and dependence on an oxygen tank, he became certain that his life would end the same way.
Although he tried to quit many times, as Yeates' health failed it seemed as if he'd be proven correct.
On New Year's Day 2013, Yeates was sitting in the kitchen of his home in Rhodes Corner, Nova Scotia when he began to feel ill. He lay down and stayed down for days, until his children called an ambulance.
On Jan. 4, the day before his youngest daughter's 16th birthday, Yeates was admitted to the hospital and spent the next five days fighting for his life against a bad case of pneumonia. He survived and returned home with his own diagnosis of late-stage emphysema and a new determination to stay off cigarettes.
He held off for five days.
After several months and follow-up tests, Yeates' doctor told him he had lung cancer and, at best, a few years to live. He still couldn't stop smoking.
Yeates hasn't beaten his nicotine addiction, but he also hasn't touched tobacco since September 1, 2013, the day he first tried an electronic cigarette.
Today, Yeates is using his remaining time and waning strength to advocate for vaping as a safer alternative to cigarettes. He sees it as a crusade to save other smokers from the slow death that he's suffering.
Yeates' fight comes at a time when governments around the world are grappling with how to regulate e-cigarettes.
Last February, the European Union revised the Tobacco Products Directive, adopting a restrictive policy around e-cigarettes and in the United States, after many legislative battles, the Food and Drug Administration is readying to introduce its own regulations.
The Canadian federal government has been slow to develop policy around vaping and Ottawa is continuing to study how to legislate the use and sale of e-cigarettes. In May, the Ontario legislature passed Bill 45, the Making Healthier Choices Act, which, among other things, bars the sale of e-cigarettes to people under 19, prohibits their use in spaces where smoking is not allowed, and restricts their display and advertisement. British Columbia and Quebec are expected to follow Ontario's lead in the coming months and many municipalities have already passed bylaws governing e-cigarettes.
Much of the legislation developing around e-cigarettes is the product of an abundance of caution from anti-tobacco advocates and policymakers who are wary of vaping and worry that, like light cigarettes before them, e-cigarettes are merely a rebranding of the same old poison, a ploy to get another generation hooked. But while there are serious and unanswered public health questions around e-cigarettes, some proponents warn that overly strict regulations may discourage smokers from making the switch to a product that leading medical experts and a wealth of scientific research is coming to support as a much less dangerous alternative to smoking and a potential boon in the fight against tobacco.
One such expert is Dr. Mark Eisenberg, a professor of medicine at McGill University and the director of the Cardiovascular Health Services Research Group and Montreal's Jewish General Hospital.
Eisenberg studies the effectiveness of smoking cessation medications, or quit-aids, and is leading a team conducting a study examining whether e-cigarettes are generally effective in helping people quit tobacco. Eisenberg says that the science is still out on this point, but that the question of how the health effects of vaping compare to those of smoking is largely settled.
"There is no question that the typical contents of e-cigarettes are less harmful than those found in tobacco cigarettes," Eisenberg wrote in an email to VICE. "E-cigarettes have no tobacco combustion, unlike regular strength or light cigarettes, which makes them much safer to use.
"Although we can't yet say for sure whether they are effective tools for smoking cessation, they are at least safer alternatives to cigarette smoking, which makes them useful tools for harm reduction."
"Orders of Magnitude Safer"
In name and nicotine content, e-cigarettes are very much like their combustible counterparts. Beyond that, however, chemical analyses show the two to be very different.
The components generally found in the liquids used in e-cigarettes are propylene glycol, glycerin, nicotine, and a flavouring agent, which is in turn a compound with multiple components.
Propylene glycol and glycerin are common food and pharmaceutical additives and are generally recognized as safe by the United States Food and Drug Administration and Health Canada. Nicotine is highly addictive and dangerous to ingest, but it does not cause cancer and is widely used as a medicine to assist smokers in quitting.
The flavouring agents used in e-cigarettes vary widely and some, most commonly sweet flavours, have been found to contain harmful chemicals.
When compared to breathing fresh air, vaping is risky. But comparing it with smoking tobacco is another story.
Cigarette smoke is an odious mix of gases, vapours, and solids containing hundreds of toxic chemicals, 70 of which are known to cause cancer. The carcinogenic potency of this mix comes mostly from tar, the solid byproduct of burning tobacco, but many of the chemicals in the gases also do significant damage to the body, especially the lungs.
Although they do it slowly, on average, cigarettes kill one in two smokers.
Many toxic chemical compounds are created through the combustion of the solid components of cigarettes, and the same is true of vaporizing an e-liquid. But with e-cigarettes, the chemicals produced are generally either present in amounts dramatically lower than those found in cigarette smoke or in amounts so small as to be insignificant.
As one 2014 study published in the journal Tobacco Control concludes, "The vapor generated from e-cigarettes contains potentially toxic compounds. However, the levels of potentially toxic compounds in e-cigarette vapor is from 9 to 450-fold lower than those in the smoke from conventional cigarettes, and in many cases comparable to the trace amounts present in pharmaceutical preparation. Our findings are support [for] the idea that substituting tobacco cigarettes with electronic cigarettes may substantially reduce exposure to tobacco-specific toxicants."
This is not the controversial conclusion of one test. It is representative of the consensus finding of many studies and is born out by a meta analysis of the existing scientific literature.
Dr. Peter Selby, chief and clinician scientist in the addictions division of the Centre for Addiction and Mental Health and professor in the departments of Family and Community Medicine and Psychiatry at the Dalla Lana School of Public Health at the University of Toronto, says that the reasons for this difference are fairly simply: vaping doesn't combust tobacco nor produce tar.
"From a product-to-product comparison, common sense will tell us that the e-cigarette is likely to be orders of magnitude safer," Selby told VICE. "Some of the research suggests 85 percent safer."
However, Selby says that the low standard of quality control under which many e-liquids are produced creates variability in their content, not just between brands, but between different batches of the same brand's liquid.
Some e-liquids producers employ high standards for product testing and consumer protection, but the proliferation of mom-and-pop vape shops and the common practice of "home-brewing" e-liquids has resulted in some dangerous chemicals finding their way into liquids without the producer's knowledge.
One such chemical is diacetyl. A flavouring agent linked to a potentially fatal respiratory disease, diacetyl was found to be present in as many as 74.2 percent of sweet e-liquids in 2014. Producers responded promptly to this finding, and the levels of diacetyl found in e-cigarette vapours were significantly lower than those found in tobacco smoke.
Selby warns that without better quality control throughout the industry, vapers face potential risks.
Selby also cautioned that although propylene glycol and glycerin are non-toxic and safe in the short-run, until there is epidemiological research looking at the effects of inhaling a high volume of these substances over decades, uncertainties will remain.
A product-to-product, ingredient-to-ingredient comparison clearly shows that e-cigarette are substantially less harmful than tobacco cigarettes, but the calculus of public health is more complex than this simple equation and some of the important variables remain unknown. One of these is addiction.
Won't Stop? Can't Stop
Ray Yeates started smoking in Dorchester Penitentiary, but not until his second stay in 1968.
"I'll never forget my first cigarette," said Yeates. "My uncle in Dorchester gave it to me. I took a drag off it and, you know, I had to be one of the tough guys, one of the Yeates, not show any sign of weakness. But you know what? I turned fucking white."
Yeates grew up around crime. His father—to whom he is not biologically related—was a car mechanic in Spryfield, Nova Scotia who occasionally stole booze from the Nova Scotia Liquor Corporation to slake his alcoholism. Yeates' many uncles were of another calibre and bounced in and out of federal prison.
Working in his father's garage, Yeates got really good at hotwiring cars. In 1965, at the age of 16, he landed in prison for the first time after stealing a maroon '61 Chevy.
In March of 1968, Yeates and a couple friends smashed the window of a service station and made off with the cash box. They were caught and Yeates landed back in Dorchester, where he spent most of the next seven years. This time, he picked up smoking in earnest.
"In jail [smoking] was just constant. It was part of it. I used to work out with weights and all that kind of stuff, and even then it was just constant."
Yeates was released from prison in 1975 smoking about a pack a day. His preference was for Player's Lights, but when money was tight he'd smoke the slightly-cheaper Canadian Classics.
Determined to get out of the environment that had helped turn him to crime, Yeates fled Atlantic Canada for Thunder Bay, Ontario. He spent much of the next five years there drinking.
As a skinny kid with an alcoholic father and a cadre of uncles with serious criminal record, Yeates says that he turned to booze early as a way to look tough, an elixir for courage in the face of stress and confrontation.
In Thunder Bay, Yeates was a partier, not the type of drunk to always have a bottle in hand. But when he did drink it was often until his memory became a dark pool that he'd slog out of hours or days later, unsure of how bad decisions were made.
"That was my problem with alcohol," said Yeates. "I blacked out a lot, an awful lot. My drinking ended up being mostly weekends. I loved to party. I loved music, Bob Marley and all that kind of stuff, pretending I was a peaceful guy when inside I was boiling over. I had a lot of hate."
"May 20, 1980" is a phrase that Yeates speaks with the grim conviction common among recovering people. It's the day he went to his first AA meeting.
Yeates hasn't had a drink or used drugs since, and spent several years working at a halfway house, helping other alcoholics and drug addicts take the first steps towards recovery. But despite his knowledge of addiction and having strength enough to help other addicts back to their feet, Yeates couldn't stop smoking.
Asked how many times he tried to quit over his three-and-a-half decades of sobriety, Yeates responded with shame at the high number: "Oh, God! I don't want to tell you. I stopped stopping because I was a failure. And sober I'm still a failure; I can't do it."
Quitting is incredibly difficult. At least half of American smokers have tried to quit within the last year. Of those who go at it cold-turkey, 95 to 97 percent fail, most within the first eight days. Smokers who use nicotine replacement therapies like the patch and support groups do a bit better, but after a year 85 percent of them are back to using cigarettes.
"At about two hours, the withdrawal is so severe that all a smoker can think about is getting to a cigarette," said Kellie Forbes, a nurse who works in acute and palliative care in Westlock, Alberta and smoked for almost 35 years before picking up an e-cigarette in May, 2013. "It's horrible. You're an absolute slave to it."
For days after an attempt to quit, as the person goes deeper into withdrawal, they will be irritable, prone to picking fights and snapping at people around them. For Yeates, this part of quitting posed a special difficulty.
As a recovering person who drank in part as a way to deal with confrontation and conflict, Yeates worried that the ill-temper that results from nicotine withdrawal might create a situation where he'd be tempted to have a drink.
"The irritability that comes with it is just extreme. You want to jump down people's throats," said Yeates. "Obviously we [recovering people] don't want the confrontation. We look at it and we can't handle confrontation."
Forbes did not have this same added barrier that Yates experienced, but despite her work— caring for people dying horribly from smoking related illnesses—she was just as unable to stop.
"I've done patches, gum, LifeSign, which was this little handheld computer. I did the Canadian Cancer Society's quitting smoking program twice. I've been on Zyban a multitude of times. I tried hypnosis, acupuncture. I tried cold turkey. I've been on Chantix four times, with horrible, horrible side effects. The side effects got worse every time I went on that drug, but I was so desperate to quit because I hated smoking. I absolutely hated it."
For Yeates and Forbes, vaping allowed them to put down cigarettes when nearly everything else had failed, and there is significant evidence that thousands of other smokers are using e-cigarettes as a way reduce or eliminate their tobacco consumption.
One survey published in the American Journal of Preventative Medicine found that out of 5,939 current and former smokers who vape in Canada, the United States, the United Kingdom and Australia 79.8 percent used e-cigarettes because they were less harmful, 75.4 percent said they used them to help reduce smoking and 85.1 percent said they used the devices to help them quit altogether.
The wide acceptance of vaping among smokers and the close similarity between the experience of using an e-cigarette and smoking are cited by medical professionals as reasons to be optimistic about the potential of e-cigarettes for smoking cessation.
However, both Selby and Eisenberg caution that there is not yet enough scientific data to say whether or not e-cigarettes can serve as an effective quit-aid at the population level. While surveys might be suggestive and stories like those of Yeates and Forbes are moving, the doctors say that what is needed are studies with long timeframes and randomized control groups comparing the effect of e-cigarettes to those of placebos and established smoking cessation therapies.
Because e-cigarettes are a new technology, there have only been a few studies that fit these criteria. The best of them, according to a literature review performed by Eisenberg's research team in preparation for their own study, is a 2013 randomized control trial that compared the effect of an e-cigarettes with nicotine, e-cigarettes without nicotine, and a nicotine patch, on 657 smokers, motivated to quit. Over six months, the study found that 7.3 percent of the nicotine e-cigarette group managed to continuously abstain from smoking, compared to 5.8 percent of those with the patch and 4.1 percent of those with the placebo.
Selby and Eisenberg said that while this study is suggestive, methodological issues with how its analysis was performed make it far from definitive and the nascency of the evidence must shape how healthcare professionals deal with vaping.
"Health practitioners, including myself, are routinely asked by patients if they should try e-cigarettes to quit smoking," Eisenberg told VICE. "Given that we don't yet know whether they are as effective as proven smoking cessation therapies (nicotine replacement, bupropion, varenicline), I typically recommend these first-line smoking therapies if a patient wants to quit smoking. However, if that patient has tried these therapies unsuccessfully, does not want to use them, or is not trying to quit smoking, I would tell them that using an e-cigarette is less harmful than smoking tobacco cigarettes."
Because the data presently available about how e-cigarettes are being used and who is using them only offer snapshots of behaviour at a particular moment, rather than tracking it over an extended period of time, there remain many other unknowns about e-cigarettes.
Two of the most important, according to Selby, are how frequently people vape as compared to smoking and whether, at the population level, e-cigarettes are a way in which people transition away from using cigarettes or if they lead people to start smoking. On these points, the technology is simply too new to know for sure.
Ultimately, Selby says, looking at e-cigarettes the way we look at medical devices is a deeply misguided approach.
"When I look at e-cigarettes as a quit-aid, I think it's probably the wrong headed way for society to go... the question we really need to ask is, how well do e-cigarettes replace combustible cigarettes in the market so that you essentially don't need to have combustibles in the market anymore."
"I think we'll see the Remington effect," said Selby, answering his own question with a reference to what computer word processing did to typewriters. "That's what you want. It's replaced. Gone."
"Easy on Harm"?
Yeates can walk across his living room or he can talk on the phone, but to do both is a struggle that leaves him coughing and reaching for the albuterol inhaler he uses to cope with emphysema.
According to Forbes, these symptoms are common among patients with chronic obstructive pulmonary disease, whose bodies gradually shut down as their organs starve for oxygen.
"At that point, what exactly kills them? Well, disease. Which one? Pick one," Forbes told VICE. "It's usually a very slow death, and it's very hard on the family, and I'm sure in the back of everyone's mind is, 'If Dad only just quit smoking... '"
In May, Yeates had wanted to travel to Toronto as part of the Tobacco Harm Reduction Association, the vaping advocacy group of which he and Forbes are members, protest of Ontario's Bill 45. However, his poor health didn't allow him to make the trip.
Yeates says that he understands the need to prohibit vaping in places like provincial buildings and the areas around schools, but he and many other e-cigarette users opposed Bill 45 because they believe that some of provisions, like the ban on displaying and giving potential users information about e-cigarettes, will discourage people from making the switch from tobacco.
Bill 45 passed overwhelmingly into law, but there is no implementation date for the e-cigarette regulations. Politicians who supported the bill say that they are waiting for more evidence to determine how the restrictions on the display and marketing of e-cigarettes should be brought into effect.
From 1997 to 2003 Clive Bates was the director of the United Kingdom anti-smoking group Action on Smoking and Health. After a period as a public servant, Bates returned to his former field, citing "unfinished business" with tobacco harm reduction. He now runs a private consultancy.
Bates, who receives no money from tobacco, pharmaceutical, or e-cigarette companies, is a proponent of e-cigarettes as a means to stopping the damage done by smoking. He is also a supporter of the regulation of e-cigarette, especially provisions that provide consumer protections in the form of manufacturing quality controls, childproof packaging, truthful advertising, accurate labeling and other things.
Looking at the present and developing legislation in North America and Europe, Bates is concerned that policymakers are striking the wrong balance, not focusing enough on quality control and too much on restricting e-cigarettes, something Bates believes is ultimately a service to the tobacco industry.
"If you're tough on harm reduction, it's not a big leap of logic to suggest that you are being easy on harm," Bates told VICE.
Yeates also worries that too much of the debate over e-cigarettes focuses on the unknowns about vaping rather than on what is known about how it compares to smoking.
"The ideology of 'quit or die' is just not the right one, because six million people a year are affected by this, plus the families," said Yeates. "That's what this has got to be about, bringing out the real effects of smoking versus the effects of the electronic cigarette."
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