Vaping crisis: A major public health concern

Happy New Year to all our readers! I wish you a very happy, healthy, and prosperous 2020!

With the beginning of this new decade, it is time for us to look towards the future and what health behaviour changes we, as a profession, might be able to influence. As I reflected on what editorial topic might be of interest to all of you, I could not help but think about how often new products are introduced and placed on the market too quickly with insufficient evidence of their potential for harm over the long term. A perfect example that comes to mind is e-cigarettes. When e-cigarettes (ECs) were introduced approximately 14 years ago, they were thought to be a potentially healthy alternative to conventional cigarettes and, in particular, a means to assist individuals in smoking cessation. If we “fast forward” to the end of 2019, we have been apprised of an alarming number of deaths (52 to date), reported in the United States, that have been associated with e-cigarette use or vaping.¹ In addition to these deaths, vaping-associated lung illnesses have also been reported in the United States, affecting approximately 2,409 people.¹ Although no deaths have been reported in Canada yet, the Government of Canada is actively investigating the emergence of these vaping-associated lung illnesses also known as “severe pulmonary illness associated with vaping.”

As of January 7, 2020, 15 cases of vaping-associated lung illness have been reported to the Public Health Agency of Canada.² Case profiles and products used by these individuals are available for all 15 cases.² Of these individuals, 11 required hospitalization and all but one are now recovering at home. Four (4) of these individuals were reported to have respiratory symptoms such as shortness of breath and cough while the 11 others presented with a combination of respiratory, gastrointestinal and/or constitutional symptoms such as fever and weight loss.

The provinces where these cases were found are as follows:

• British Columbia (3)

• Alberta (1)

• Ontario (4)

• Quebec (5)

• New Brunswick (2)

Salme E Lavigne

In addition, these individuals ranged in age from 15 years to more than 50 years of age without any real age trends. Since little is known about the long-term effects of vaping, Health Canada has released an information update warning Canadians about the potential risk of pulmonary illness associated with vaping products and, in particular, warns youth, pregnant women, and those who do not currently vape not to vape.³ Health Canada has also partnered with the Public Health Agency of Canada and now has a webpage to keep the public informed about Canadian cases of severe pulmonary illness related to vaping.² The latest number of confirmed or probable cases of severe vaping-related pulmonary illness in Canada will be posted and updated weekly on this website, as is done in the United States by the Centers for Disease Control and Prevention.

Dozens of chemicals that are not found in conventional cigarettes can potentially be found in vaping products in addition to nicotine. Some of these additives are flavours, metals, rubber, silicone, and ceramics. Significant amounts of metals (most likely from solder joints, wires, etc.) and silicate beads (most likely from the fiberglass wick) have been found in ECs.⁴ It is well known that occupational exposure to silicate dusts can cause extensive pulmonary damage.⁵ Similar to conventional cigarettes, e-cigarettes contain concentrations of lead and chromium, however the range of nickel has been reported to be 100 times higher than in conventional cigarettes. E-fluid has also been found to contain tin and to be cytotoxic.⁴ Interestingly, most of these metals appear on the US Food and Drug Administration’s list of Harmful and Potentially Harmful Constituents in Tobacco Products and Tobacco Smoke. ⁶

Despite these recent issues with vaping, Health Canada has been reported to be considering changing the rules that prevent vaping companies from making any health-benefit claims and may make an exception to allow e-cigarette manufacturers to use promotional statements suggesting that vaping products are safer than conventional cigarettes. This possibility has caused an uproar within the medical community, with physicians, researchers, and health organizations such as the Canadian Cancer Society and the Heart and Stroke Foundation, all of whom believe that allowing companies to make such claims would be a “critical misstep.” Such statements could downplay the risks of e-cigarettes and could potentially encourage more young people to vape. A staff respirologist from Toronto’s Hospital for Sick Children told reporters at The Globe and Mail that there was “no credible evidence showing that vaping products are safer than traditional cigarettes and companies should not be allowed to promote such an idea.”⁷

Health care professionals including dental hygienists should always ask clients as part of their medical history update if they use drugs from any source, legal or illegal, including e-cigarettes. If clients present with respiratory symptoms, particularly if the cause is unclear, dental hygienists should ask if they use vaping products and what devices and liquids they use. I believe as a preventive health profession whose major role is health promotion, we need to voice our objection to Health Canada regarding the potential advertising of e-cigarettes as less of a risk than traditional cigarettes. We are already experiencing the fallout of not having sufficient evidence of the safety and efficacy of these products; to allow such advertising seems to me to be going in the wrong direction.

The danger to society is not merely that it should believe wrong things...but that it should lose the habit of testing things and inquiring into them...

—William Kingdon Clifford, The Scientific Basis of Morals (1884)