1. Charles Gardner, MD, CCFP, MHSc, FRCPC Medical Officer of Health Simcoe Muskoka District Health Unit October, 2016

2. Relationships with Commercial Interests: Grants/Research Support: none Speakers Bureau/Honoraria: provided to SMDHU Consulting Fees: none Clinical Trial: none Other: OMERS pension fund content

3. E-cigarettes should always be considered in the context of the tobacco epidemic.

4. SMOKING: STILL ONE OF THE TOP PREVENTABLE CAUSES OF DEATH Source: SEVEN MORE YEARS: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. Institute for Clinical Evaluative Sciences, Public Health Ontario

5. THE ARRIVAL OF E-CIGARETTES – THE “WILD WEST”

6. Potential for resurgence of youth smoking  E-cigs prevalence of use increasing from 15% to 22.6% - 2013 to 2015, Ont.  Smoking and Health Foundation / Association of Local Public Health Agencies THE TWO COMPETING PERCEPTIONS OF E-CIGARETTES – POTENTIAL THREAT

7. THE TWO COMPETING PERCEPTIONS OF E-CIGARETTES – POTENTIAL BENEFIT Disruptive innovation that aids in the tobacco end game  David Sweanor, Legal Council, Nonsmokers’ Rights Association “Can the rise of the e-cigarette… do what the refrigerator did for stomach cancer – by making the cigarette and perhaps all forms of combusting of tobacco obsolete?”

8. PUBLIC HEALTH ENGLAND: “95% LESS HARMFUL THAN SMOKING.” Duncan Selbie, Chief Executive

9. CHEMICAL EXPOSURES Firsthand  Tobacco smoke levels between 40 to 2800 fold higher than E- cigs for: Formaldehyde, acetaldehyde, acrolein, VOCs, Nitrosamines - Laugesen 2015, Goniewicz et al. 2014  Exposure to the ‘butter’ flavor chemical (diacteyl) causes lung scarring  E-cigarette vapour and cigarette smoke comparable for five metals (copper, magnesium, lead, chromium, manganese) - Williams et al (2013) Secondhand  Nicotine from smoking tobacco cigarettes 10 times higher than from e-cigarettes - Czogala et al. 2014  Particulates 13-fold higher from tobacco use than e-cigs - Saffari et al. 2014

10. GATEWAY FOR YOUTH SMOKING Source: Barrington-Trimis J, et al. E-Cigarettes and Future Cigarette Use. Pediatrics, June 13, 2016.

11. POSSIBLE BENEFITS? COCHRANE COLLABORATION, SEPT 2016: No evidence emerged that short-term EC use is associated with health risk. Low certainty of benefit:  Cessation 2 RCTs compared with placebo / EC without nicotine: increased the chances of stopping smoking in the long term –Low confidence due to small numbers of studies and wide confidence intervals 1 RCT compared with nicotine patches found no difference in cessation –Low confidence for similar reasons  Reduced cigarette consumption - 2014 (compared with placebo ECs and nicotine patches), Same limitations as above Lack of biochemical assessment.  A further 15 ongoing RTCs

12. WHERE DO WE GO FROM HERE? PUBLIC HEALTH  Overall Approaches: Prevent youth / nonsmoker initiation of use Possible cessation / harm reduction benefit for smokers (low certainty) More research needed  Public health approaches Regulation options: –Prohibit sales to minors – in place –Prohibit use in indoor public places and work places – not yet in place –Restrictions on marketing – not in place –Product restrictions – flavouring, content disclosure – not in place

13. WHERE DO WE GO FROM HERE? CLINICAL PRACTICE Advise to patients: Counsel against use for nonsmokers – particularly youth Continue full range of smoking cessation supports Informed consent approach re limited research on cessation / reduction