Category: Harm Reduction series

Posted on

E-cigarettes: On the Vapour Trail for Harm Reduction

Electronic cigarettes (e-cigs) have become a fad consumer product in several countries and are banned in others.  Here in Canada, nicotine-containing products are regulated (de facto banned) by Health Canada, and non-nicotine e-cigs are legal for sale.  However, nicotine products are openly sold in e-cig boutiques in Canada and are available online.

Everyone seems to ask one of two questions: “Are e-cigs harmful?” or “Are e-cigs less harmful than smoking?”
ImageIn a year or so, tobacco control researchers expect to have enough published studies for evidence-based recommendations on e-cigs.  Here is some of the data available now on the composition of inhaled and exhaled vapor.

Sellers and most users believe that what they are “vaping” (inhaling) is the base ingredient (propylene glycol and/or glycerine), flavouring ingredients, and nicotine (or none). However, research has detected other harmful substances in e-cig vapour, including formaldehyde, acetaldehyde, nickel, chromium, and lead.  Some vapour testing has identified lead and chromium concentrations equivalent to cigarettes, and nickel concentrations two to 100 times higher than in Marlboro cigarette smoke.  Yet the potential for harm reduction is evidenced by a study finding the average levels of 12 toxic substances in vapour to be nine to 450 times lower than in cigarette smoke. 

Now what about second-hand vapour?  Vapour has been demonstrated to produce second-hand nicotine exposure, even though nicotine levels in second-hand vapour were one tenth of those in smoke from tobacco cigarettes. For example, one study showed that of the 20 compounds present in second-hand smoke, e-cigs produced four of them, with three at significantly lower levels than cigarettes. However, one study found similar levels of nicotine biomarkers in research subjects exposed to second-hand vapour as to second-hand smoke.

Research to date informs us that vapour has fewer toxins than cigarette smoke, and has comparatively lower concentrations of other harmful compounds.  But e-cigs do produce problematic toxic exposures, and vapour does add some toxins to the air.  With studies documenting airborne nicotine and positive tests for second-hand nicotine exposure, the precautionary principle would subject vaping to current smoking bans to protect bystanders, as recommended by the German Cancer Research Centre.

Many more questions need to be addressed, including product safety and the potential increase in population rates of nicotine use, before the healthcare community will be able to assess if e-cigs can be endorsed for harm reduction.  In the meantime, e-cig users continue to vape, hoping that they are reducing their health risks, and bystanders breathe in vape, hoping that it is harmless.

From the available research, one fact is clear: while e-cig vapour exhibits potential for harm reduction, e-cig vapour is not harmless water vapour.

Author: Renee O’Leary, PhD student, Centre for Addictions Research of BC, University of Victoria

renee

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Posted on

The Federal Government and Safe Injecting Sites: Why the Ongoing Resistance?

It is no secret that the consequences of drug addiction are severe, sometimes even fatal. Imagine, for a moment, an opportunity that offered a completely different outcome for Canadians suffering from the stigma that surrounds severe addiction.

Imagine an opportunity that provided a welcome environment free of judgment to those most entrenched in their disease.  A setting that has repeatedly proven to substantially reduce the chance of acquiring a life threatening infectious disease or die from a drug overdose.  A place where one could access health care services without shame, engage in medical detoxification and be referred for other addiction treatment.

It would be hard to comprehend why anyone would not be in support of such a program.  Yet that is exactly where we find ourselves with the federal government’s entrenched opposition to Vancouver’s supervised injecting facility, Insite.

ImageDespite a wealth of scientific evidence repeatedly demonstrating the success of Insite in reducing harms associated with illicit drug use and widespread endorsement for the program from numerous health bodies, including the Canadian Medical Association, the federal government went all the way to the Supreme Court of Canada in an effort to have Insite shut down.  They were ultimately unsuccessful when a unanimous 2011 decision stipulated the facility remain open and also described how the government must consider applications for future programs.

The government’s response?  Announcement of its “Respect for Communities Act.” A Bill so onerous it seemed geared towards making it
Imageimpossible for any organization to meet eligibility criteria to even submit a future application.  Ultimately, the Bill did not become law but was quickly succeeded by the introduction of Bill C2

The government’s stark opposition to supervised injecting facilities is rather confusing given their support for other health interventions for intravenous drug users.  At the 2008 International AIDS Conference, former Health Minister Tony Clement made clear the Conservatives’ support for needle exchange programs, which involve handing out clean needles to addicts and have proven effective at reducing the spread of infections like HIV.  In the case of Insite, however, Clement made clear his strong opposition to the program famously calling it an “abomination.”

The irony is that needle exchange programs do essentially the same function as Insite but they don’t regulate how and where the needles are used.  For instance, individuals using a needle exchange may take a needle and subsequently inject in full view of the public and then dispose of the needle in parks or other areas where there is a risk of needle stick injury.  Contrast this with Insite, where injections take place out of the public view, away from vulnerable youth, and onsite disposals ensure used needles can not find their way into public spaces.  Strict rules and nursing supervision also precludes the possibility of a used syringe being passed between users at Insite, a behavior primarily responsible for the spread of HIV among this population and not fully prevented by traditional needle exchange programs.  Locally, Insite has contributed to a 90 percent reduction in new HIV cases in BC, which is remarkable given each new HIV infection costs on average $500,000 in medical costs.  Insite also forces its clients to temporarily remain onsite after injecting where an addiction treatment program is co-located.  As a result a study published in the New England Journal of Medicine demonstrated that weekly use of supervised injecting facilities was associated with a greater than 70 percent increase in the use of medical detoxification among its clients.

Despite these clear successes, and the ability of the program to reduce public drug use and the spread of disease and death, the federal government remains firm in their opposition to supervised injecting facilities.  Unfortunately, many desperately addicted Canadians’ lives currently hang in the balance as a result.

What further evidence does the government need to support this lifesaving program?

Authors: Seonaid Nolan, MD, FRCPC and Evan Wood, MD, FRCPC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC