1. UPDATE IN SIMCOE MUSKOKA, AND E-CIGARETTES SMTCC – Who’s Who & What’s New in Smoking Cessation December 9, 2014 Lisa Simon, MD, MPH, CCFP, FRCPC Associate Medical Officer of Health Simcoe Muskoka District Health Unit

2. OVERVIEW Local epidemiology Current topics:  New provincial legislation  Ontario Smoking Cessation System proposal  Smoke-free housing E-cigarettes

3. OVERVIEW

6. TOBACCO USE Epidemiology – prevalence trends?

8. CURRENT TOPICS

9. NEW: SMOKE-FREE ONTARIO ACT (SFOA) REGULATION, EFFECTIVE JAN 1, 2015 Prohibit smoking on all bar and restaurant outdoor patios. Prohibit smoking on playgrounds, publicly owned sporting areas, and adjacent spectator areas. Prohibit tobacco sales on post-secondary education campuses.

10. NEW: PROPOSED SFOA AMENDMENTS Ban the sale of flavoured tobacco products, with delayed implementation date for menthol-flavoured tobacco products. Increase maximum fines for those who sell tobacco to youth. Strengthen enforcement to allow for testing of substances used in waterpipes (e.g. hookahs, shisha) in indoor public places. [Ontario also intends to amend regulations to further restrict smoking on outdoor grounds of hospitals.]

11. NEW: PROPOSED MAKING HEALTHIER CHOICES ACT, 2014 E-cigarettes legislation:  Ban the sale and supply of e-cigarettes to anyone under the age of 19.  Prohibit the use of e-cigarettes in certain places where the smoking of tobacco is prohibited.  Ban the sale of e-cigarettes in certain places where the sale of tobacco is prohibited.  Prohibit the display and promotion of e-cigarettes in places where e-cigarettes or tobacco products are sold, or offered for sale.

12. ONTARIO SMOKING CESSATION SYSTEM (OSMOSYS) PROPOSAL Initiative of CAMH, Canadian Cancer Society, and U of Ottawa Heart Institute Goal: integrated system for tobacco cessation in Ontario Key elements:  Coordinated protocol with shared language, procedures and linked processes for interacting with health care organizations, health care professionals, and people who smoke;  Centralized data capture, data management, and treatment routing;  Combined and integrated training platform and service provider network. Status: proposal currently being submitted to province

13. SMOKE-FREE HOUSING Multi-unit dwellings (MUDs) still routinely site of SHS exposure Smoke-free MUDs protect non-smokers, and like other smoke-free policies may → ↑ quitting and ↓ initiation of tobacco 70% of non-smoking adults living in MUDs in Simcoe Muskoka support smoking ban (RRFSS, 2011-13) Progress in Simcoe Muskoka:  Building awareness, and supporting transitions to smoke-free MUDs  Have had many units transition to smoke-free, beginning with social housing

14. E-CIGARETTES Cartridge – Atomizer – Battery

15. HEALTH CANADA’S POSITION E-cigarettes for nicotine useIllegal E-cigarettes not for nicotine use that make a health claim Illegal Nicotine cartridges/liquidIllegal E-cigarettes not for nicotine use that do not make a health claim Legal

16. SFOA: DOES NOT APPLY

17. PREVALENCE OF E-CIGARETTE USE Canadians aged 16-30 yrs. (Czoli, Hammond, & White, 2014):  16% tried an e-cigarette  Current and former smokers more likely than non-smokers to have tried (OR 10 and 4, respectively)  Smokers tried in order to: help quit smoking (80.4%), long- term replacement for cigarettes (77.8%), use in places where cannot smoke (80.9%)

18. E-CIGARETTES AS CESSATION AID 1 RCT (Bullen et al, Lancet, 2013):  No sig diff in verified abstinence from quit day to 6-month f/u between 3 trial arms: 7·3% with 16 mg nicotine e-cigarettes, 5·8% with 21 mg patches, and 4·1% with no-nicotine e-cigarettes (risk difference for nicotine e-cigarette vs patches 1·51 [95% CI –2·49 to 5·51]; for nicotine e-cigarettes vs placebo e-cigarettes 3·16 [95% CI –2·29 to 8·61]) 5 observational studies (4 longitudinal, 1 cross-sectional) and 3 clinical trials without control group Overall:  Evidence limited and inconclusive  E cigarette use associated with reduction in cigarette use rather than quitting - high levels of dual use with cigarettes

19. HEALTH RISKS Less harmful than conventional cigarettes, but not risk-free Adverse effects of nicotine exposure Particulates  Passive vaping Potential for nicotine poisoning Unknown: harms of long term use?

20. RISKS TO TOBACCO CONTROL Gateway to nicotine addiction and/or smoking for youth? Re-normalize smoking behaviours? Undermine smoking bans? Dual Use: undermine quitting?

21. THE ROLE OF BIG TOBACCO

22. MARKETING AND SALES

26. SMDHU’S ACTIONS SMDHU Position: Electronic cigarettes should be prohibited anywhere smoking is currently prohibited, whether provincially or municipally mandated, including public places and workplaces. Have advocated accordingly to provincial and federal gov’ts Supporting e-cigarette policy work by municipalities, school boards, post secondary, and others, before and after provincial legislation comes into force

27. WHEN YOUR PATIENTS ASK YOU ABOUT USING E-CIGARETTES… What do you say? Grana et al, E-cigarettes: A scientific review, Circulation 2014: “If a patient has failed initial treatment, has been intolerant of or refuses to use conventional smoking cessation medication, and wishes to use e-cigarettes to aid quitting, it is reasonable to support the attempt.” Caveats:  Fully informed  Don’t use indoors or around children  Set a quit date for e-cigarette use  Quit smoking entirely

28. ACKNOWLEDGEMENTS - SMDHU Penny Rush, Chronic Disease Prevention - Tobacco Program, Public Health Nurse Rebecca Harbridge, Chronic Disease Prevention - Tobacco Program, Public Health Nurse Lee Zinkan-McKee, Chronic Disease Prevention - Tobacco Program, Manager Non-Smokers Rights Association

29. THANK YOU